# patient right to demand ambulance transport



## medic01 (Sep 21, 2011)

so as the title infers. The question is the same if a patient is deemed to have no acute of life threat, does the patient have the right to demand transport via ambulance. If so are there any regulatory statutes to back this up.


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## usafmedic45 (Sep 21, 2011)

Nope, at least not anywhere I have worked.  If they start getting hostile about it, they will end up with a ride in another variety of emergency vehicle though.


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## Voodoo1 (Sep 21, 2011)

I'm a little confused by your question. How would a pt you have assessed, even if you can't seem to find anything wrong, be turned out by EMS thus having the patient having to demand to be taken? Could you give a scenario so that people could better understand your question?


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## JPINFV (Sep 21, 2011)

Some systems allows for alternative transport decisions or for paramedic initiated refusals of care.


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## Katy (Sep 21, 2011)

Never heard of such a thing.


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## the_negro_puppy (Sep 21, 2011)

If a patient wants an ambulance, they get one. We cannot refuse a patient a ride to hospital unless it endangers ourselves.


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## medic01 (Sep 21, 2011)

Scenario 
You get called for a pt who is complaing of general illness. Upon arrival you find a 23 year old female. No apparent distress and states to providers both Fire and EMS that she just needs a ride to her doctors appointment. After verifying there is no medical emergency and documenting inform her that we can not transport her to her doctor's appointment. She still insists on being transported by ambulance. 

Second scenario. 

You arrive on scene of a 40 year old man. Call was for unknown medical. Pt is AOx4. Pt is homless and his only complaint is it is to hot outside and wants to be taken to a hospital that is 40 miles away bypassing several closer facilities. Scene control once again states that he called 911 and we should just get him out of the city. Pt later states prior to transport that his friend lives by requested hospital and he knew he could get a free ride and just sign out AMA, on arrival.


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## medic01 (Sep 21, 2011)

the_negro_puppy said:


> If a patient wants an ambulance, they get one. We cannot refuse a patient a ride to hospital unless it endangers ourselves.


If that is the case where does it say that. That is like saying that just because you called 911 you have to go to the hospital. I understand we have an obligation to treat and transport life threats but do we also not have a duty to educate our public on proper use of emergency services. Some agency's i believe have forgotten this.


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## Flightorbust (Sep 21, 2011)

Depending on how you want to look at it, failure to transport could be called abandonment. Now you can refuse to take your pt. to x hospital if y hospital is closer.


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## DrParasite (Sep 21, 2011)

medic01 said:


> Scenario
> You get called for a pt who is complaing of general illness. Upon arrival you find a 23 year old female. No apparent distress and states to providers both Fire and EMS that she just needs a ride to her doctors appointment. After verifying there is no medical emergency and documenting inform her that we can not transport her to her doctor's appointment. She still insists on being transported by ambulance.


she gets the ride to the hospital.  we don't transport her to her doctor's office, but if it's in the hospital, than we get to play taxi.  and yes, i have been the taxi for just such a ride.


medic01 said:


> You arrive on scene of a 40 year old man. Call was for unknown medical. Pt is AOx4. Pt is homless and his only complaint is it is to hot outside and wants to be taken to a hospital that is 40 miles away bypassing several closer facilities. Scene control once again states that he called 911 and we should just get him out of the city. Pt later states prior to transport that his friend lives by requested hospital and he knew he could get a free ride and just sign out AMA, on arrival.


Per my State's Dept of Health, we must transport the patient anywhere they want to go (and yes, when I mentioned crossing state lines, I was told anywhere they want to go).  we get used as a cross town taxi all the time too.

If they call for the ambulance, taken em to the hospital of their choosing, unless you have an administrative support in writing saying you can deny them transport.


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## the_negro_puppy (Sep 21, 2011)

medic01 said:


> If that is the case where does it say that. That is like saying that just because you called 911 you have to go to the hospital. I understand we have an obligation to treat and transport life threats but do we also not have a duty to educate our public on proper use of emergency services. Some agency's i believe have forgotten this.



Let me re-write that. Our Ambulance service is run by and paid for by the State. Anyone who calls 000/911 is entitles to an ambulance and we are not allowed to refuse transport to anyone unless it is dangerous to do so. That is our current policy.  

I wish we could refuse in certain circumstances.


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## JJR512 (Sep 21, 2011)

DrParasite said:


> Per my State's Dept of Health, we must transport the patient anywhere they want to go (and yes, when I mentioned crossing state lines, I was told anywhere they want to go). we get used as a cross town taxi all the time too.
> 
> If they call for the ambulance, taken em to the hospital of their choosing, unless you have an administrative support in writing saying you can deny them transport.


 
In Maryland we transport to the closest appropriate facility, as per protocols. Gee, I guess I finally found one example where MD isn't so backwards (in the opinion of many other members here, not including myself) compared to other jurisdictions.


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## bigdogems (Sep 21, 2011)

In any 911 systems that I've worked. 1. We only transport to an ER. 2. Closest facility (for the complaint/problem) We can not flat out refuse transport to an ER. We will always offer to take the pt to the ER. If they refuse to go to one of the options we have for an ER they can find a ride from a family member/friend or call a private


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## usalsfyre (Sep 21, 2011)

JJR512 said:


> In Maryland we transport to the closest appropriate facility, as per protocols. Gee, I guess I finally found one example where MD isn't so backwards (in the opinion of many other members here, not including myself) compared to other jurisdictions.



Errrr, so in MD your not allowed any choice in where your transported to, it's solely up to a possibly lazy burned out provider?


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## usalsfyre (Sep 21, 2011)

We can't refuse transport. Both cases get transported, with accurate documentation as to the reason for the call. 

I am curious about the "scene control saying get them out of the city". What exactly does that mean? How are transport decisions not up to the transporting medic?


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## 18G (Sep 21, 2011)

In my area anyway if a patient calls 911 we are not allowed to refuse transport to a hospital. We have no alternative care programs so ambulance transport to a hospital is our only option. 

If 911 is called, EMS responds, patient want's to go to the hospital, why would EMS refuse?

It's kinda like a patient goes to the hospital ED, triage nurse calls BS, and tells patient they can't be seen. Eh.. no.


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## 46Young (Sep 21, 2011)

medic01 said:


> Scenario
> You get called for a pt who is complaing of general illness. Upon arrival you find a 23 year old female. No apparent distress and states to providers both Fire and EMS that she just needs a ride to her doctors appointment. After verifying there is no medical emergency and documenting inform her that we can not transport her to her doctor's appointment. She still insists on being transported by ambulance.
> 
> Second scenario.
> ...



Some regions have a "no need for EMS" guideline. That's where someone calls, and there really and truly is nothing wrong with them. This could apply to someone that walks into the station to have their BP check, for example. This guideline has limited applications, of course.

In general, once pt contact is established, they're yours until they can be handed off to a qualified provider of equal or higher capabilities, or delivered to a 911 receiving hospital. Other countries have systems where the pt can, in fact, be taken to a MD's office, an urgent care, or straight to a psych. facility, for example, but not here in the U.S. You can't just tell them that you can't take them where they want to go, and then leave. That would be pt abandonment; you need to have them sign an RMA first, to absolve you of liability.

Example one - Inform the pt that your service can only transport to a 911 receiving facility, which is the hospital ED. Inform them that you are not authorized to transport anywhere else. Inform them that either you can transport them to the hospital, or they can sign the refusal; that's it. The 911 system does not provide transport to tertiary facilities for appointments and procedures; that is not the role of this type of service. Inform them that a private interfacility ambulance service can provide this service for them, for a fee.

Example 2 - systems ought to have guidelines stating how far past the closest 911 receiving hospital you're allowed to transport. For example, in NYC, it's ten minutes past the closest appropriate hospital. In others, it's the closest appropriate period. This is to stem 911 abuse such as what you're describing. Refer to your local guidelines, or call your EMS supervisor on the scene if you're not sure what to do. If no guidelines address txp destinations, then bring this to the attention of admin, who would stand to benefit from not having their units OOS for long, frivolous txp times, often for the uninsured and underinsured to begin with.


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## dixie_flatline (Sep 21, 2011)

usalsfyre said:


> Errrr, so in MD your not allowed any choice in where your transported to, it's solely up to a possibly lazy burned out provider?



The patient is allowed to make a request, but we certainly don't have to listen to the request - as long as the hospital we choose is a facility that can provide the care they require.  

We can't decline a transport unless it's unsafe, but at the same time we aren't beholden to a patient's whims as to where they go.  How far can a patient dictate you transport them?


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## Sasha (Sep 21, 2011)

That "Wherever they want to go" is silly... What if they're in South FL on vacation and want to go to their hospital in GA? Are some of you people saying that you'd have to transport them on something like that??


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## Shishkabob (Sep 21, 2011)

18G said:


> If 911 is called, EMS responds, patient want's to go to the hospital, why would EMS refuse?



Because the vast majority of patients don't need an ambulance, let alone care during an ambulance transport?



Quit being lazy / cheap.  Get a taxi.  Save the ambulance for someone that needs it.


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## STXmedic (Sep 21, 2011)

I believe I'm mildly spoiled here.....


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## 18G (Sep 21, 2011)

Linuss said:


> Because the vast majority of patients don't need an ambulance, let alone care during an ambulance transport?
> 
> 
> 
> Quit being lazy / cheap.  Get a taxi.  Save the ambulance for someone that needs it.



I completely agree. Im not even remotely saying that all 911 calls are legit. And yes it would be nice to be able to screen patients and refer them to alternate care services other than transport to an ED. Unfortunately EMS isn't set up that way in most parts of the country. 

I can see the headline now... "EMS crew refuses to transport patient, patient dies two hours later".


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## thegreypilgrim (Sep 21, 2011)

JPINFV said:


> Some systems allows for alternative transport decisions or for paramedic initiated refusals of care.


 Do you happen to know the relevant legal references for this in California? My attempts at researching this haven't yielded any results.


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## Shishkabob (Sep 21, 2011)

18G said:


> I completely agree. Im not even remotely saying that all 911 calls are legit. And yes it would be nice to be able to screen patients and refer them to alternate care services other than transport to an ED. Unfortunately EMS isn't set up that way in most parts of the country.
> 
> I can see the headline now... "EMS crew refuses to transport patient, patient dies two hours later".



Mistakes happen.  How often do you see doctors misdiagnose something and a patient ends up dying?  Yet I don't see anyone demanding hospitals be shut down.     If you aren't going to die soon, you don't need an ambulance, but NO ONE is stopping you from driving yourself.




The reason why healthcare is the way it is in this country is due to the feeling of entitlement people have.  They think they are entitled to an ambulance transport just because their toe hurts.  They think they're entitlted to every single diagnostic test in a hospital due to an ear infection.  They think they're entitled antibiotics for a simple infection that the body should fight off in no time.


Then they think they're entitled to having it cheap, and when it isn't, they refuse to pay, which raises the costs for others who DO pay, which leads to a viscous cycle.



We just need to get the balls up and say "No, you don't need this."


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## Sasha (Sep 21, 2011)

Linuss said:


> Mistakes happen.  How often do you see doctors misdiagnose something and a patient ends up dying?  Yet I don't see anyone demanding hospitals be shut down.     If you aren't going to die soon, you don't need an ambulance, but NO ONE is stopping you from driving yourself.
> 
> 
> 
> ...



First before we need balls we need education to know that just because theyre not bleeding or flopping around gasping for breathe doesnt mean their condition is not serious and in need of immediate attention.

And the education is not there for many paramedics yet.

Sent from LuLu using Tapatalk


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## 18G (Sep 21, 2011)

Linuss said:


> Mistakes happen.  How often do you see doctors misdiagnose something and a patient ends up dying?  Yet I don't see anyone demanding hospitals be shut down.     If you aren't going to die soon, you don't need an ambulance, but NO ONE is stopping you from driving yourself.
> 
> The reason why healthcare is the way it is in this country is due to the feeling of entitlement people have.  They think they are entitled to an ambulance transport just because their toe hurts.  They think they're entitlted to every single diagnostic test in a hospital due to an ear infection.  They think they're entitled antibiotics for a simple infection that the body should fight off in no time.
> 
> ...



You and I may be able to handle this approach but think of the many ALS providers short changing the patient and not taking them to the hospital because they are lazy, lack the ability to do a good assessment, are plain ****s, or don't feel like getting off an hour past their shift. 

Unless we have a system in place to refer these patients right then and there (ie nurse line, etc), we don't have an option really unless it is blatantly obvious an ambulance ride isn't necessary.


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## 18G (Sep 21, 2011)

Sasha said:


> First before we need balls we need education to know that just because theyre not bleeding or flopping around gasping for breathe doesnt mean their condition is not serious and in need of immediate attention.
> 
> And the education is not there for many paramedics yet.
> 
> Sent from LuLu using Tapatalk



Agree. More education is needed. Definitely possible, but not with the way EMS works in most places right now.


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## JPINFV (Sep 21, 2011)

thegreypilgrim said:


> Do you happen to know the relevant legal references for this in California? My attempts at researching this haven't yielded any results.




It's not really something I can reference. Personally, I thought it was common knowledge that a handful of systems allowed, or at least toyed with, paramedic initiated refusals. From what was discussed at Expo in Vegas (Community Paramedicine session), Austin and a few other systems have had great success with community paramedicine trials and alternative transport options. Let me email a few people and see if I can get something I can link to.

Edit: I also don't know of any *legal* references. I've always assumed that transport decision in California were set at the LEMSA level and not the EMSA/legislative level. I was actually sort of surprised that the APP proposal included the option to refuse or alternative transport option simply because I've always assumed that there was nothing at the state level limiting it.


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## Shishkabob (Sep 21, 2011)

MedStar in Fort Worth has Advanced Practice Paramedics (Community Paramedics) that can refuse to transport a known system abuser.   They even advertise that ability on their info of APPs.


Don't know the percentages on it, but it's there.


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## JJR512 (Sep 21, 2011)

usalsfyre said:


> Errrr, so in MD your not allowed any choice in where your transported to, it's solely up to a possibly lazy burned out provider?


 
What part of "transport to the closest appropriate facility" makes you think that anything is up to the provider at all, lazy/burned out or not?

The truth is, as dixie_flatline explained, the patient can make any request they want. They will get transported to the closest appropriate facility. Extenuating circumstances will be considered, at least in my experience they are. At my station, there are two hospitals that, in different directions, are near enough to the same distance away as makes no difference that if the patient prefers one over the other, we'll honor their request. But there is none of this "transport the patient wherever they want to go" nonsense.

And one more thing...In Maryland, a patient has just as much chance of getting a "possibly lazy burned out provider" as they would in any other state, and frankly, the attitude I detect in that question can get shoved. In deference to forum rules, I won't say where.


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## Handsome Robb (Sep 21, 2011)

46Young said:


> systems ought to have guidelines stating how far past the closest 911 receiving hospital you're allowed to transport.



In my system the patient can request any facility they want, but we don't transport to out of area hospitals unless you meet the criteria to go there. In my system would only be burn center criteria and in that case your going by HEMS seeing as your looking at 2 1/2-3 hours by ground to the nearest burn center.

We have 4 hospitals in our area, One Level II which along with 2 others have cath labs and accept stroke patients. The 4th being a satellite center off the level II that is working on putting a cath lab in but for now is just a basic ER.


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## usalsfyre (Sep 21, 2011)

JJR512 said:


> What part of "transport to the closest appropriate facility" makes you think that anything is up to the provider at all, lazy/burned out or not?
> 
> The truth is, as dixie_flatline explained, the patient can make any request they want. They will get transported to the closest appropriate facility. Extenuating circumstances will be considered, at least in my experience they are. At my station, there are two hospitals that, in different directions, are near enough to the same distance away as makes no difference that if the patient prefers one over the other, we'll honor their request. But there is none of this "transport the patient wherever they want to go" nonsense.
> 
> And one more thing...In Maryland, a patient has just as much chance of getting a "possibly lazy burned out provider" as they would in any other state, and frankly, the attitude I detect in that question can get shoved. In deference to forum rules, I won't say where.


Obviously it was a loaded question. However, there's a large (perhaps majority) group of paramedics who's ability to determine "appropriate facilities" I seriously question. Both on the over and undertriage categories. Your right however that you can encounter these in any state. In addition, who determines "closest appropriate" when say insurance is involved? Because if you refuse to go 15 minutes further to a hospital that's in-network for me I'm going to be seriously pissed, and your not doing your patient any favors sticking them with a higher bill.

Finally, yes I poked at your myopic defense of the Maryland EMS system. I urge you again to explore the world outside of MD and why the only people who say they are the best are involved in the MD EMS system.


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## 18G (Sep 21, 2011)

I agree that a patient has the right to request and be transported to a hospital of their choice as long as it is reasonable distance. 

The patient is ultimately in charge (given a life or death issue) and when they are footing the bill they better have a say on where they receive their medical care. 

Too many EMS providers tend to forget that the patient is not powerless in the back of the ambulance and that the patient has the right to decide their care. That right is not forfeited because they dialed 911.   

In my region, we have taken patients an hour away to their hospital of choice. That is pretty much the limit for distance. Patient also needs to be made aware that insurance won't cover the additional mileage.


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## the_negro_puppy (Sep 21, 2011)

The question of "how far" we should transport patients is a complex one.

We have a number of public and private hospitals within my city, all within about 30 or so minutes drive away. We generally take patients where they want to go within reason. But what is within reason? driving past 4 different hospitals for a wound that requires sutures because the patient "heart specialist" works there? It different for us here as although the patient may be indirectly 'footing the bill' through taxes (ambulances are free for residents of the state)they are not directly out of pocket.

When you are already on overtime past your finish time is it reasonable to 'taxi' someone past 4 different hospitals or take them to the closest suitable ED? Some may argue that if they call 911/000 then they are sick enough to go to the closest suitable hospital. 

The needs and wants for the patient needs to be balanced with the needs of the local community. Should an ambulance be tied up taxiing patients 30kms past multiple hospitals? deny other potential sicker people an ambulance?

I don't know what the answer is but I try to accommodate most peoples needs whether it be due to continuity of care/ pt hx at the hospital, or preference.

I think paramedics should be able to refuse transport to hospital within certain guidelines. As others have said, most people calling ambulances probably don't need one, let alone to be seen in an ED. Dispatchers should also have some authority for refusing Ambulances based on strict guidelines such as a caller requesting an ambulance with simple isolated complaints such as minor cuts, runny noses and minor aches and pains.


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## JPINFV (Sep 21, 2011)

18G said:


> Patient also needs to be made aware that insurance won't cover the additional mileage.



Medicare might not, but the private companies may. Otherwise they're just going to have to pay for a second transport anyways.


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## JPINFV (Sep 21, 2011)

the_negro_puppy said:


> The needs and wants for the patient needs to be balanced with the needs of the local community. Should an ambulance be tied up taxiing patients 30kms past multiple hospitals? deny other potential sicker people an ambulance?


It's not quite that simple in non-single payor systems. How many people are in the ED waiting for a transfer to an in-network hospital for admission, and how does that affect hospital diversions and offload times? If the problem is so bad, the ability to drive 10-15 minutes further could easily align the needs of the many with the needs of the individual. 




> Dispatchers should also have some authority for refusing Ambulances based on strict guidelines such as a caller requesting an ambulance ...runny noses ...



Call the police. They're better with runners.


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## Shishkabob (Sep 21, 2011)

18G said:


> Too many EMS providers tend to forget that the patient is not powerless in the back of the ambulance and that the patient has the right to decide their care. That right is not forfeited because they dialed 911.   .



No, but it does piss me the hell off when they go that route without any rhyme or reason.   You call for my help, but refuse every single way I can help?  Just take a taxi, it will be cheaper and I can do good for someone else.


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## Hunter (Sep 21, 2011)

*Yay for once Florida got it right.*



Sasha said:


> That "Wherever they want to go" is silly... What if they're in South FL on vacation and want to go to their hospital in GA? Are some of you people saying that you'd have to transport them on something like that??



Thankfully in most of south Florida the county/city run EMS crews only transport to nearest facility, for something like this we have ton of IFT ambulance companies which would probably be called. Of course in any scenario where the patient doesn't require immediate transport they'd probably call an IFT company to come pick em up.


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## mycrofft (Sep 22, 2011)

*Parse it.*

Do they have a *right*? 
No.

Might they be in a district that has policy to transport everyone they encounter?
Yes.

Is it prudent to transport every single person who demands it?
If every one is sick or injured or it is in your policies and it is safe, then yes.

"Message is hazy, try again later".


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## 46Young (Sep 22, 2011)

NVRob said:


> In my system the patient can request any facility they want, but we don't transport to out of area hospitals unless you meet the criteria to go there. In my system would only be burn center criteria and in that case your going by HEMS seeing as your looking at 2 1/2-3 hours by ground to the nearest burn center.
> 
> We have 4 hospitals in our area, One Level II which along with 2 others have cath labs and accept stroke patients. The 4th being a satellite center off the level II that is working on putting a cath lab in but for now is just a basic ER.



That's what I meant by closest "appropriate."


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## Epi-do (Sep 22, 2011)

Around here, we cannot refuse to transport anyone that requests an ambulance takes them to the ER.  That being said, most crews have learned how to "strongly encourage" those that would be better suited seeing their primary care physician, or treatment somewhere other than an ER, to find other modes of transportation.  That being said, there will always be those out there that continue to insist the ambulance take them, regardless of what is going on at the time.

As for which ER we transport to, it really depends upon the situation.  There are a couple hospitals within 10-15 minutes of the area I work in.  One of the campuses has a heart center and is a stroke center.  The three level I trauma centers are about double that away, and then there are a handful of other hospitals we also go to, all about 30 minutes or so drive away.  

If the patient is having a STEMI, they all go to the closest heart center for stabilization.  They can then be transferred to the hospital of choice from there, if they desire.  The same goes for stroke patients. 

If the patient's issue requires the resources of one of the level I's that we have, even though they are sicker than most patients, they get the slightly longer ride.  All of the level I's are within 5 minutes of each other, so if the pt is conscious, we can still give them a choice of hospitals, although it is much more limited, if we choose to do so.  Often times, we choose which level I we are going to take them to for treatment, though.  

All other patients get to choose the hospital we take them to for treatment, as long as it is within the county I work in.  We have two hospitals that are exceptions to that, and we do transport to them, despite their locations being in another county, because they are within 20-30 minutes transport time.


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## LondonMedic (Sep 22, 2011)

I don't understand some of your American systems.

When we were debating patients' right to refuse treatment, how many people wanted to wait until the patient was unconscious before kidnapping them and dragging them in?

Now we're talking about patient that _want_ to go in...


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## CAOX3 (Sep 22, 2011)

The patient is allowed hospital of choice "within reason". However I determine whats "within reason"

I will  take you where you want to go but Im not driving across the state because your cousins half sisters daughter is a CNA there.

Sorry.


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## usalsfyre (Sep 22, 2011)

LondonMedic said:


> I don't understand some of your American systems.
> 
> When we were debating patients' right to refuse treatment, how many people wanted to wait until the patient was unconscious before kidnapping them and dragging them in?
> 
> Now we're talking about patient that _want_ to go in...



The problem is most paramedic schools here spend all of about 4 hours on legal issues. So everything gets distilled down to "call med control, and take the patient in if any doubt otherwise YOU'LL GET SUED!! ". True informed consent and refusal as well as patient self-determination are fairly foreign concepts.

Couple this with a lack of alternative care pathways and a system that values emergency over routine care and you end up with this odd dichotomy.


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## Shishkabob (Sep 22, 2011)

LondonMedic said:


> When we were debating patients' right to refuse treatment, how many people wanted to wait until the patient was unconscious before kidnapping them and dragging them in?
> 
> Now we're talking about patient that _want_ to go in...



A patient that had their toe nail ripped off wants a CT of their head done even though there is no reason.  Do you comply?


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## JPINFV (Sep 22, 2011)

usalsfyre said:


> The problem is most paramedic schools here spend all of about 4 hours on legal issues. So everything gets distilled down to "call med control, and take the patient in if any doubt otherwise YOU'LL GET SUED!! ". True informed consent and refusal as well as patient self-determination are fairly foreign concepts.
> 
> Couple this with a lack of alternative care pathways and a system that values emergency over routine care and you end up with this odd dichotomy.




...and isn't it about 0 hours of training in determining which patients actually needs a hospital?


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## usalsfyre (Sep 22, 2011)

JPINFV said:


> ...and isn't it about 0 hours of training in determining which patients actually needs a hospital?



Depends on the program. I actually had to take some pathophys and assessment classes that aided in that area greatly. 

A "just enough to get past the NR" program? Probably zero hours. 

Didn't the last paper on the subject say (granted I wasn't thrilled with it) paramedics are great at determining need for prehospital intervention but not need for admission?


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## JPINFV (Sep 22, 2011)

usalsfyre said:


> Didn't the last paper on the subject say (granted I wasn't thrilled with it) paramedics are great at determining need for prehospital intervention but not need for admission?




News flash, people who aren't trained in something are generally bad at it.


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## usalsfyre (Sep 22, 2011)

JPINFV said:


> News flash, people who aren't trained in something are generally bad at it.



Yep, that was the big issue I had with the publication. If I remember correctly it made no attempt to quantify education levels of the medics involved, and then, after determination that they do indeed suck at determining need for admission no education was provided to see of the deficiency could be easily corrected.


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## JJR512 (Sep 22, 2011)

usalsfyre said:


> In addition, who determines "closest appropriate" when say insurance is involved? Because if you refuse to go 15 minutes further to a hospital that's in-network for me I'm going to be seriously pissed, and your not doing your patient any favors sticking them with a higher bill.


Insurance isn't factored into the equation at all, period. "Closest appropriate" means "closest _medically_ appropriate. The decision is made based on the medical needs of the patient, which in my opinion, is all that matters. Making medical decisions based on insurance or financial or convenience considerations is a big part of what's wrong with medicine today, in my opinion.

Further in my opinion—and a whole separate topic can be started from what I'm about to say—a patient shouldn't have to pay more in an emergency because the ambulance personnel decided the patient should go to Hospital Y instead of Hospital X.

Finally, if I have to transport you an additional 15 minutes out, and have a 15 minute additional return to quarters time, for no real medically relevant reason, is the 30-minute loss of time available fair to the community I'm supposed to be serving?



> Finally, yes I poked at your myopic defense of the Maryland EMS system. I urge you again to explore the world outside of MD and why the only people who say they are the best are involved in the MD EMS system.


Why should I "explore the world outside of MD"? I live in MD. I have no intention of ever moving out of MD. Knowing what Texas or South Dakota would do in a particular situation won't help me in that situation because I can only do what MD allows me to do.

I read this forum and I read JEMS magazine, and occasionally some sources. I read them with an attitude of "what can I learn", not "how are other jurisdictions better than mine".

Finally, I don't recall ever saying that MD EMS is the best EMS system. I think you're stereotyping me, assuming that because I'm in EMS in MD, I'm exactly the same as some other MD EMS people you've experienced. I know several other MD EMS people on this forum and they don't really fit your stereotype, either. Maybe your stereotype is flawed.


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## JPINFV (Sep 22, 2011)

JJR512 said:


> Making medical decisions based on insurance or financial or convenience considerations is a big part of what's wrong with medicine today, in my opinion.



So the solution is to make the situation worse in the short term in a manner that would do nothing to generate a long term solution?




> Finally, if I have to transport you an additional 15 minutes out, and have a 15 minute additional return to quarters time, for no real medically relevant reason, is the 30-minute loss of time available fair to the community I'm supposed to be serving?



Sure, when it saves you an equal 30 minutes of time holding the wall because the ED isn't waiting for the local IFT service to transport your prior patient to, when all things are considered, the most appropriate facility. 




> Why should I "explore the world outside of MD"? I live in MD. I have no intention of ever moving out of MD. Knowing what Texas or South Dakota would do in a particular situation won't help me in that situation because I can only do what MD allows me to do.




I read this forum and I read JEMS magazine, and occasionally some sources. I read them with an attitude of "what can I learn", not "how are other jurisdictions better than mine".[/quote]

Because what MD allows will never change? 

If another jurisdiction is doing something better than you, shouldn't that be something that you would want to introduce to make your own system better?


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## Sasha (Sep 22, 2011)

JJR512 said:


> Insurance isn't factored into the equation at all, period. "Closest appropriate" means "closest _medically_ appropriate. The decision is made based on the medical needs of the patient, which in my opinion, is all that matters. Making medical decisions based on insurance or financial or convenience considerations is a big part of what's wrong with medicine today, in my opinion.
> 
> Further in my opinionand a whole separate topic can be started from what I'm about to saya patient shouldn't have to pay more in an emergency because the ambulance personnel decided the patient should go to Hospital Y instead of Hospital X.
> 
> ...



Insurance should be taken into consideration for that. Who are you helping by sticking them with a big bill they cant pay? Its time to stop thinking of the patient as an emergency and start thinking of them as a patient and take into consideration what their best interest is, within reason.

Sent from LuLu using Tapatalk


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## usalsfyre (Sep 22, 2011)

JJR512 said:


> Insurance isn't factored into the equation at all, period. "Closest appropriate" means "closest _medically_ appropriate. The decision is made based on the medical needs of the patient, which in my opinion, is all that matters. Making medical decisions based on insurance or financial or convenience considerations is a big part of what's wrong with medicine today, in my opinion.


So doing what's right for the patient isn't really important in your view?



JJR512 said:


> Further in my opinionand a whole separate topic can be started from what I'm about to saya patient shouldn't have to pay more in an emergency because the ambulance personnel decided the patient should go to Hospital Y instead of Hospital X.


I agree 100%, but it's not the reality of the situation at the moment.



JJR512 said:


> Finally, if I have to transport you an additional 15 minutes out, and have a 15 minute additional return to quarters time, for no real medically relevant reason, is the 30-minute loss of time available fair to the community I'm supposed to be serving?


So your more concerned with potential patients than the overall well-being of the patient who presents to you? This is why unit move-ups and mutual/automatic aid exist. The stress and anxiety over "how am I going to pay for this" (a very real concern to many people) is not going to be helpful. This is one of the big issues I have with viewing EMS through the "public safety" prism rather than the "medicine" prism. 



JJR512 said:


> Why should I "explore the world outside of MD"? I live in MD. I have no intention of ever moving out of MD. Knowing what Texas or South Dakota would do in a particular situation won't help me in that situation because I can only do what MD allows me to do.


Because one day you may be in a position to make policy. 



JJR512 said:


> I read this forum and I read JEMS magazine, and occasionally some sources. I read them with an attitude of "what can I learn", not "how are other jurisdictions better than mine".


Recognizing flaws is important in the QA/QI process.



JJR512 said:


> Finally, I don't recall ever saying that MD EMS is the best EMS system. I think you're stereotyping me, assuming that because I'm in EMS in MD, I'm exactly the same as some other MD EMS people you've experienced. I know several other MD EMS people on this forum and they don't really fit your stereotype, either. Maybe your stereotype is flawed.


Like all stereotypes, it's by nature flawed. But your continual defense of MDs system makes you somewhat of a target.


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## JJR512 (Sep 22, 2011)

JPINFV said:


> So the solution is to make the situation worse in the short term in a manner that would do nothing to generate a long term solution?


Can you explain how transporting a patient to the closest medically-appropriate facility is making the situation worse in the short term?

If there are two hospitals and both are equally medically suitable for the patient's needs, isn't going to the closer of the two, thus getting the patient to the care he or she needs sooner, the soundest medical decision?



> Sure, when it saves you an equal 30 minutes of time holding the wall because the ED isn't waiting for the local IFT service to transport your prior patient to, when all things are considered, the most appropriate facility.


First of all, do recall that I already stated the patient is going to an appropriate facility. Therefore, when I bring the patient into the ED, they're already in the appropriate facility, and there is no medical reason for the patient to be transported somewhere else.

Secondly, we are not held at a hospital to wait for an IFT service to show up to transfer the patient from our stretcher to theirs. It just doesn't happen. I don't know if there are rules against that or if the hospitals around here just have too much common sense for that, but if that's the kind of thing that happens where you are, sorry for your luck. And now that your objection has been eliminated, the question remains: Is it fair to the community I'm supposed to serve for me to be unavailable for extended periods of time just because a patient had a non-medical desire to go to a farther hospital, when there was a closer hospital that was able to handle the patient's needs just as well?



> Because what MD allows will never change?
> 
> If another jurisdiction is doing something better than you, shouldn't that be something that you would want to introduce to make your own system better?


Although some members here would vehemently disagree, MD can and does change. I've seen numerous changes to the protocols just about every year since I first became an EMT-B in 2006. But I am nowhere near experienced or knowledgeable enough yet to know what is better, nor am I in any position to introduce improvements. Maybe someday, but not now. And I can say with certainty right now that I will _never_ automatically assume that just because some other state is doing it differently from Maryland, that they are automatically better, and again, I'm sure some people here will strongly disagree with that. But when people like that tell me it's stupid to believe that MD is always best (which I don't, nor have ever said), they fail to realize that it's equally stupid to believe that MD is always worst.


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## Shishkabob (Sep 22, 2011)

Maybe if enough people get pissed at getting bills from hospitals because their insurance refuses to pay even though it's the most medically appropriate facility, congress will do it's job and fix the problems that really matter, instead of the ones that make them look good...???



Ha.. congress do it's job.  I'm a comedian today.


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## JPINFV (Sep 22, 2011)

JJR512 said:


> Can you explain how transporting a patient to the closest medically-appropriate facility is making the situation worse in the short term?



Increased out of pocket costs. I'm not saying that a 911 unit in Maryland needs to transport a patient to San Diego, but if the in-network hospital is 10 minutes further away, then I find it hard to justify not transporting the majority of patients to their hospital of preference. 



> If there are two hospitals and both are equally medically suitable for the patient's needs, isn't going to the closer of the two, thus getting the patient to the care he or she needs sooner, the soundest medical decision?


It depends. Assuming the patient isn't in an immediate life-threatening state, if the patient is going to be transferred prior to admission, then how does transporting to the non-home hospital make a sound medical decision? If the patient wants to go to hospital B because that's what the hospital their primary care physician has practice rights at, then the sound medical decision is to transport the patient to his home hospital. The vast vast majority of patients are not suffering from a condition where an additional 10 minutes is going to change their outcome. 

How is transporting a patient to a hospital where treatments may be denied due to insurance/reimbursment issues make a sound medical decision?

Where does increasing out of pocket expense for no medical gain make a sound medical decision? 




> First of all, do recall that I already stated the patient is going to an appropriate facility. Therefore, when I bring the patient into the ED, they're already in the appropriate facility, and there is no medical reason for the patient to be transported somewhere else.


Do you understand how insurance works? Are you seriously suggesting that patients are not transferred between hospitals for insurance reasons? 



> Secondly, we are not held at a hospital to wait for an IFT service to show up to transfer the patient from our stretcher to theirs. It just doesn't happen. I don't know if there are rules against that or if the hospitals around here just have too much common sense for that, but if that's the kind of thing that happens where you are, sorry for your luck. And now that your objection has been eliminated, the question remains: Is it fair to the community I'm supposed to serve for me to be unavailable for extended periods of time just because a patient had a non-medical desire to go to a farther hospital, when there was a closer hospital that was able to handle the patient's needs just as well?


No, you're going to hold the wall because some of the beds are inhabited by patients who need to be admitted and are waiting to be transferred to the most appropriate  hospital for them, which includes issues like insurance. This isn't about your stretcher to another service's stretcher. This is about opening up a bed so that you can move your patient to the hospital's bed. Last time I checked, gurneys don't get doubled up with patients. 

So, no, the comment has not been eliminated because you misunderstood the concern. Have you never had to hold the wall because of no beds available? 




> But I am nowhere near experienced or knowledgeable enough yet to know what is better, nor am I in any position to introduce improvements.


Damn, it must suck to not be able to talk to people who move and shake things, even though I bet they have this new fangled thing like e-mail that facilitates communication. Similarly, I feel sad that you feel you're incapable of gathering information to make suggestions. Heck, even asking, "Why don't we have/do ____" may plant the seed in someone who can directly effect change. 

I don't buy the "I can't directly change anything, therefore it doesn't matter what I know or don't know" line. 





> And I can say with certainty right now that I will _never_ automatically assume that just because some other state is doing it differently from Maryland, that they are automatically better, and again, I'm sure some people here will strongly disagree with that.


Because I so completely said that anything different automatically means that Maryland is wrong. :unsure:


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## Sasha (Sep 22, 2011)

Cost can be a discouraging factor when a patient needs an ambulance but doesnt want to call because of the bill, especially when the ambulance wont take them to the in network hospital

Sent from LuLu using Tapatalk


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## JJR512 (Sep 22, 2011)

JPINFV said:


> Increased out of pocket costs. I'm not saying that a 911 unit in Maryland needs to transport a patient to San Diego, but if the in-network hospital is 10 minutes further away, then I find it hard to justify not transporting the majority of patients to their hospital of preference.
> ...
> It depends. Assuming the patient isn't in an immediate life-threatening state, if the patient is going to be transferred prior to admission, then how does transporting to the non-home hospital make a sound medical decision? If the patient wants to go to hospital B because that's what the hospital their primary care physician has practice rights at, then the sound medical decision is to transport the patient to his home hospital. The vast vast majority of patients are not suffering from a condition where an additional 10 minutes is going to change their outcome.


Your talking about a financial situation. I'm talking about a medical situation. I'm an EMS provider, not a financial advisor. The patient called 911 because they believed they had an emergency need to get to the hospital. If the patient's medical condition is such that an extra 10, 15, or even 30 minutes in an ambulance is of no medical signficance, then in my opinion, they don't really need to be in the ambulance in the first place, and it would be cheaper for them to call a taxi or pay a friend some gas money to take them wherever they want to go. There, I just saved the patient a bunch of money (ambulance rides being much more expensive than taxis) _and_ freed up valuable EMS resources in one fell swoop. Yippee! 



> How is transporting a patient to a hospital where treatments may be denied due to insurance/reimbursment issues make a sound medical decision?


In Maryland, by law, life-saving treatments cannot be withheld due to the patient's financial status or ability (or lack thereof) to pay. Period.

Now you may point out that you're not talking about life-saving treatments. Again, if the patient really has time to worry about saving some money, they should call a taxi.



> Do you understand how insurance works? Are you seriously suggesting that patients are not transferred between hospitals for insurance reasons?


I said, "...there is no medical reason for the patient to be transported somewhere else." Let me re-emphasize part of what I said: "no *medical* reason". What part of me talking about medical reasons makes you think I'm suggesting something based on insurance reasons?

Personally, I feel that transferring a patient solely for insurance reasons is stupid. It costs more money to transfer someone by ambulance than it does to just treat them where they are, and insurance companies only willing to pay some doctors and not others is a big problem with modern healthcare. But that's a whole different topic right there.



> No, you're going to hold the wall because some of the beds are inhabited by patients who need to be admitted and are waiting to be transferred to the most appropriate hospital for them, which includes issues like insurance. This isn't about your stretcher to another service's stretcher. This is about opening up a bed so that you can move your patient to the hospital's bed. Last time I checked, gurneys don't get doubled up with patients.


If I go to Hospital A and all, say, 40 ER beds are occupied, and 10 of those are people waiting to get transfered to other hospitals due to insurance reasons, then like you say, I'll have to wait. But Hospital B also has people waiting to get transfered for insurance reasons, too. If I had gone there instead, I'd still have to wait.

But what if all patients always go to the hospital of their (insurance company's) choice? I'd still have to wait. There would still be just as many people going to the ER. Whether the 40 people in Hospital A's ER are all in the right place or some are waiting to get transfered, they still have all 40 beds occupied, and I'm still going to have to wait for a bed.



> So, no, the comment has not been eliminated because you misunderstood the concern. Have you never had to hold the wall because of no beds available?


Yes, and let me reiterate that it doesn't matter why the beds aren't available. If we eliminate those who should have (by your standards) gone somewhere else in the first place, those beds would be instead occupied by patients who are at that moment in other hospitals but should have gone where I am in the first place (by your standards). Either way, I'm waiting.

No matter how you cut it, time spend unnecessarily driving is time wasted, time I'm not available to my community.



> Damn, it must suck to not be able to talk to people who move and shake things, even though I bet they have this new fangled thing like e-mail that facilitates communication. Similarly, I feel sad that you feel you're incapable of gathering information to make suggestions. Heck, even asking, "Why don't we have/do ____" may plant the seed in someone who can directly effect change.
> You can take your sarcastic attitude and shove it. In deference to forum rules I won't say where.
> 
> For me, at this point, to think that I know any better than all those above me and before me is just plain arrogant. I watch and listen. I ask questions, including "why" and "why not". There's way too much I don't know and don't understand that to make a suggestion at this stage would be disastrous. I would get grilled on why is my suggestion better and I won't have all the answers because I don't even know what are all the answers I should have. And then I'd just look stupid.


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## JPINFV (Sep 22, 2011)

I'm done. If you want to continue living in the fantasy world where insurance doesn't matter and the only thing people use the 911 system is for immediate life threatening conditions, then so be it. The rest of us, who live in the real world, realize that this isn't the case can continue this discussion. 

Oh, and there's power in "why" and "why not," and someone who asks those questions can very easily get a reply along the lines of, "I don't know, why don't we do that?" Viola, the system is changed.


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## Akulahawk (Sep 22, 2011)

Insurance is just ONE reason to select one hospital over another. Another thing to consider is which facility has the patient's medical records. That's usually the facility that the patient normally goes to, where their insurance is normally accepted... 

Sure, the hospital might get patient records sent over, but how long will that take? What about you just transported someone to the _closest_ facility and now the patient has to be transported to another one for "repatriation"... how does that improve a patient's care if you can take them directly to the requested facility in the first place? 

A key thing to remember is that you should transport the patient to the closest, _most appropriate_, facility. This becomes more clear when dealing with specialty care facilities. Sure, that ED that's 8 minutes away can deal with that 35%TBSA burn patient... (they'll eventually send 'em out)... or you can transport that patient another 18 or 25 minutes to a designated Burn Center and bypass having the patient hold in a relatively poorly equipped ED for the next 2-4 hours for an available CCT unit...


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## Shishkabob (Sep 22, 2011)

Here's one for you:

I have a level 1 trauma center an hour to my east, and a level 3 45 minutes to my south.  Both are the same hospital, just separate campuses, meaning insurance works at both, medical records available at both.

I often have patients state they don't want to go to the one to the south because "They treated them wrong", but every single person I've asked to expand upon the "wrong" hasn't come up with a reason.




So... to re-iterate:  Same hospital, different campuses.  Why would it be wrong to go to the closer one, when insurance and patient info is no longer an issue, and the presenting condition is minor and non-chronic?


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## the_negro_puppy (Sep 22, 2011)

Linuss said:


> Here's one for you:
> 
> I have a level 1 trauma center an hour to my east, and a level 3 45 minutes to my south.  Both are the same hospital, just separate campuses, meaning insurance works at both, medical records available at both.
> 
> ...



Indeed I get this as well. Also like "My family member died there I want to go somewhere else" or "I heard that its a bad hospital" or "I heard the staff are bad there"

For us insurance is out of the equation as most people choose public hospitals which have no upfront cost. We do have private hospitals where if you have insurance you can be seen. Most people are happy to go to the closest hospital as its easier to get home/closer to home for them.


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## Medicus (Sep 22, 2011)

DrParasite said:


> Per my State's Dept of Health, we must transport the patient anywhere they want to go (and yes, when I mentioned crossing state lines, I was told anywhere they want to go).  we get used as a cross town taxi all the time too.
> 
> If they call for the ambulance, taken em to the hospital of their choosing, unless you have an administrative support in writing saying you can deny them transport.



Not surprising that this is coming from the state where no one knows how to pump their own gas.

There is no way that is the complete story, and if it is, I would like to see documentation to support that. A patient who can tolerate a (presumably) longer transport across state lines to another hospital doesn't require an ambulance.


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## usalsfyre (Sep 22, 2011)

Why does everyone seem to think "isn't immediately dying" is synonymous with "doesn't require an ambulance"? 

What if I have a painful, angulated long bone or hip fracture likely to require surgery (and thus admission) but the facility that is in-network for my insurance provider is 25 minutes further away. I should have to do without pain management and position of comfort transport or be stuck with a higher/multiple bills?


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## Medicus (Sep 22, 2011)

usalsfyre said:


> Why does everyone seem to think "isn't immediately dying" is synonymous with "doesn't require an ambulance"?
> 
> What if I have a painful, angulated long bone or hip fracture likely to require surgery (and thus admission) but the facility that is in-network for my insurance provider is 25 minutes further away. I should have to do without pain management and position of comfort transport or be stuck with a higher/multiple bills?



Why do you think that a long bone or hip fracture is not a medical emergency?

I just got out of the OR about 3 hours ago, but last time I checked, the femoral artery and vein run right through there (subtrochanteric hip fracture).  Avascular necrosis is also a concern, particularly in femoral head ("hip") fractures. PEs are also common with hip fractures.

But hey, good idea!


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## usalsfyre (Sep 22, 2011)

The huge majority of fractures are not time sensitive. Teching in the ED I put most fractures in plaster to be sent home. Further, I can't ever recall seeing a simple femoral head fracture with vascular comprimise.

Yet they are commonly very painful, so explain to me why they must be transported to the closest ED.


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## Akulahawk (Sep 22, 2011)

usalsfyre said:


> Why does everyone seem to think "isn't immediately dying" is synonymous with "doesn't require an ambulance"?
> 
> What if I have a painful, angulated long bone or hip fracture likely to require surgery (and thus admission) but the facility that is in-network for my insurance provider is 25 minutes further away. I should have to do without pain management and position of comfort transport or be stuck with a higher/multiple bills?


That's where knowing what's "most appropriate" comes into play. We shouldn't ever be locked into one default destination for every patient. The point that I (and probably most here) was trying to make is that we have to consider the totality of the circumstances. For instance, if I can't provide you pain management for that angulated femoral fracture... that plays a part in which facility I take you to. If I can... again, that's another factor... Add-in local protocols that specify destinations for certain kinds of patients, and things can get really futzed up. Confused much? Oh... this subject most definitely can...


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## usalsfyre (Sep 22, 2011)

Akulahawk said:


> That's where knowing what's "most appropriate" comes into play. We shouldn't ever be locked into one default destination for every patient. The point that I (and probably most here) was trying to make is that we have to consider the totality of the circumstances. For instance, if I can't provide you pain management for that angulated femoral fracture... that plays a part in which facility I take you to. If I can... again, that's another factor... Add-in local protocols that specify destinations for certain kinds of patients, and things can get really futzed up. Confused much? Oh... this subject most definitely can...



So what your saying is because some EMS systems are subpar, the patient gets to bear additional cost. 

I agree there should be some sort of "reasonable limit", that's easily spelled out in policy. Simply saying the "closest facility that can handle your problem" is inappropriate and puts the system before the patient.


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## Akulahawk (Sep 22, 2011)

usalsfyre said:


> The huge majority of fractures are not time sensitive. Teching in the ED I put most fractures in plaster to be sent home. Further, *I can't ever recall seeing a simple femoral head fracture with vascular comprimise*.
> 
> Yet they are commonly very painful, so explain to me why they must be transported to the closest ED.


They do happen... 

"Femoral neck fractures often disrupt the blood supply to the head of the  femur. The medial circumflex artery supplies most of the blood to the  head and neck of the femur and is often torn in femoral neck fractures.  In some cases, the blood supplied by the foveal artery may be the only  blood received by the proximal fragment of the femoral head. If the  blood vessels are ruptured, the fragment of bone may receive no blood  and undergo avascular necrosis (AVN)." from http://emedicine.medscape.com/article/825363-overview#aw2aab6b2b4


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## Medicus (Sep 22, 2011)

usalsfyre said:


> The huge majority of fractures are not time sensitive. Teching in the ED I put most fractures in plaster to be sent home. Further, I can't ever recall seeing a simple femoral head fracture with vascular comprimise.
> 
> Yet they are commonly very painful, so explain to me why they must be transported to the closest ED.



That's exactly it though- *teching* in the ED. You're doing it under an MD's orders who has assessed the patient and given the orders.

Also, it doesn't necessarily mean much that you don't "ever recall seeing a simple femoral head fracture with vascular comprimise"- you specifically would never see a femoral head fracture with vascular compromise because there would be no reason to tell you. Would you know what vascular compromise to the femoral head looked like if you saw it? There is a reason that patients with a hip fracture are supposed to receive AP films for three years after surgery- AVN can be insidious.


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## Medicus (Sep 22, 2011)

usalsfyre said:


> Because the huge majority of fractures are not time sensitive? Yet they are commonly very painful...



How do you know? Do you have an MRI in your ambulance? How about a mobile x-ray? Ultrasound?

By the way, there is an entire cemetery at Mons that disagrees with you.


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## abckidsmom (Sep 22, 2011)

Medicus said:


> That's exactly it though- *teching* in the ED. You're doing it under an MD's orders who has assessed the patient and given the orders.
> 
> Also, it doesn't necessarily mean much that you don't "ever recall seeing a simple femoral head fracture with vascular comprimise"- you specifically would never see a femoral head fracture with vascular compromise because there would be no reason to tell you. Would you know what vascular compromise to the femoral head looked like if you saw it? There is a reason that patients with a hip fracture are supposed to receive AP films for three years after surgery- AVN can be insidious.



I can't think of a single femoral head fracture I've ever seen go to the OR on the same day.  25 minutes wouldn't make a difference in the outcome, and if it got the patient to the facility they preferred, knew them, and was more convenient for their family and their pocketbook, how is that a problem?


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## Aidey (Sep 22, 2011)

In my area we are required to transport if the patient/family requests it. We do have a protocol that allows for the non transport of known system abusers without a legitimate complaint. It is complicated, requires a doctor to agree and to my knowledge it never gets used.

Some info on our system. There are 5 local hospitals with ERs, one of them is a VA hospital. There are two companies that each run 2 of the other ERs. Each company runs one big hospital and one little one. All 4 of them use the same medical records system, which is also used by a couple of the local lab and imaging companies. All 4 ERs are in network for the local insurance companies. 2 of the hospitals are out of network to a certain insurance only if the patient gets admitted. 

Our policy is that the patient is transported to the facility of their  choice, or the closest appropriate facility if they are unable to  choose. We are allowed to over rule patient choice, but only in select  circumstances and up to a point.

When people pick a hospital that can't handle their condition we advise them that XYZ hospital is better for whatever reason, and I've yet to have someone refuse to go to the more appropriate hospital. If they do refuse we are supposed to call the more appropriate facility and have the patient speak with a doc. If they still refuse, we transport where they want to go and document the heck out of it. 

I think the most common situation where a patient gets overruled is concerning the VA "ED". They can't do cardiac, there is not an RT there 24hrs, all radiology has to be sent out to be read, they don't have psych, etc. We can't even transport there without prior approval by the ER doc. So basically anyone who is actually sick goes to a different ER. The VA does have an arrangement where they will pay the bill if another hospital is more appropriate. 

The other situation is when we are picking up at SNFs. The vast majority of the time the patient's hospital choice is preselected which is helpful, unless that hospital isn't the most appropriate. In those cases I tend to go to the other ER run by the same company as the selected ER. This usually only happens when we suspect cardiac or CVA.


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## DesertMedic66 (Sep 22, 2011)

If the patient wants to go to the hospital then they get to go. They have 3 hospitals in our response area that they get to choose from. We transport to 2 out of our area hospitals but a patient can not request those 2 hospitals. If they want a VA hospital they just get transported to a normal hospital. From there they can set up a BLS or ALS transfer to the VA hospital.


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## medic417 (Sep 22, 2011)

It is idiotic to transport every caller that requests transport.  This leads to people learning to abuse the system.  All progressive quality systems either have or will soon have a denial of transport guideline.


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## JPINFV (Sep 22, 2011)

Denial of transport options!=rejecting reasonable requests?


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## usalsfyre (Sep 22, 2011)

So I researched who you were and it appears I'm dealing with a med student or baby doc. Meaning you've most likely never actually _*practiced*_ independently a day in your life. So, perhaps you might want to get that out of the way first, because there's probably clinicians who don't have MD behind their name that can run circles around you right now.



Medicus said:


> That's exactly it though- *teching* in the ED. You're doing it under an MD's orders who has assessed the patient and given the orders


It's impossible to take what you learn by working under someone else's direction and apply it to your own practice? Stop the presses, the whole medical education model is flawed! Not all docs require you to have a super secret physician decoder ring to teach you what their looking for.



Medicus said:


> Also, it doesn't necessarily mean much that you don't "ever recall seeing a simple femoral head fracture with vascular comprimise"- you specifically would never see a femoral head fracture with vascular compromise because there would be no reason to tell you.


Riiiiggghhhttt, I'm just the dumb tech right? There's NO reason I would EVER think to ask why's the patient being transferred in the middle of the night vs waiting till surgery comes in.



Medicus said:


> Would you know what vascular compromise to the femoral head looked like if you saw it? There is a reason that patients with a hip fracture are supposed to receive AP films for three years after surgery- AVN can be insidious.


You've neatly sidestepped the core question I asked earlier by calling into question my qualifications. Poor form. The question was...is there some reason this can't go the extra 20 minutes to my facility of choice rather than "the closest appropriate facility? 



Medicus said:


> How do you know? Do you have an MRI in your ambulance? How about a mobile x-ray? Ultrasound?


Nope, neither does a good portion of medicine elsewhere in the world. Yet they manage to do just fine. This is a tired argument. You know as well as I do the majority of problems cam be diagnosed via physical exam, diagnostic imaging is usually used to confirm, and considerably overused at that.



Medicus said:


> By the way, there is an entire cemetery at Mons that disagrees with you.


Really. An entire cemetery that died solely of vascular compromise resulting from orthopedic injuries in say, the last 25 years? Wow...

Someone said on another thread a little humility goes a long way. This is true at all levels. If you approach practice like you've approached a few discussions I've seen on this forum, your staff is going to make you life a living hell.


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## medic417 (Sep 22, 2011)

JPINFV said:


> Denial of transport options!=rejecting reasonable requests?



If patient has legitimate need of medical transport then they can be transported to a different facility that they want as long as it does not create a higher risk to the rest of the population because area will be uncovered or under covered for extended time.  What is good for one is not always good for the greater number.


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## Shishkabob (Sep 22, 2011)

Aidey said:


> When people pick a hospital that can't handle their condition we advise them that XYZ hospital is better for whatever reason, and I've yet to have someone refuse to go to the more appropriate hospital.


  I've had on insist on an inappropriate facility while having an MI before.  I was just happy I was able to convince them to go in the first place as that took 30 minutes to do.

Ended up being flown from the facility of their choice to a proper facility a short time after arrival.



Hopefully after seeing that bill, he'll listen to reason in the future.  




> If they do refuse we are supposed to call the more appropriate facility and have the patient speak with a doc.



Strangely, the doctors in my current system absolutely refuse to speak with a patient on the phone.



> The other situation is when we are picking up at SNFs. The vast majority of the time the patient's hospital choice is preselected which is helpful, unless that hospital isn't the most appropriate. In those cases I tend to go to the other ER run by the same company as the selected ER. This usually only happens when we suspect cardiac or CVA.



Once had a fall patient where all indications pointed towards a head bleed.  SNF wanted patient sent to a local hospital, who wouldn't be able to do anything.  I instead went to a much more appropriate facility.

SNF complained.  I explained reasoning to supervisors.  Supervisors backed me up.


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## DrParasite (Sep 22, 2011)

Medicus said:


> Not surprising that this is coming from the state where no one knows how to pump their own gas.


not doesn't know how to, is forbidden by state law from doing it.  many of us do know how to do it, but our fuels costs are still cheaper than other states that pump their own gas.


Medicus said:


> There is no way that is the complete story, and if it is, I would like to see documentation to support that. A patient who can tolerate a (presumably) longer transport across state lines to another hospital doesn't require an ambulance.


(609) 633-7777 is the number for the DOH, call them and ask for Regulations and Enforcement/Legal division.  That's what I did, and when I asked the question, that was what I was told.  If you get a different answer, please let me know who you speak to, because I would love to hear the updated answer.


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## Epi-do (Sep 23, 2011)

Aidey said:


> When people pick a hospital that can't handle their condition we advise them that XYZ hospital is better for whatever reason, and I've yet to have someone refuse to go to the more appropriate hospital. If they do refuse we are supposed to call the more appropriate facility and have the patient speak with a doc. If they still refuse, we transport where they want to go and document the heck out of it.



I find this interesting.  Mostly because we do the exact opposite.  We contact the hospital of choice, and fill them in on the patient condition with the patient/family right there to hear all the traffic.  Once that hospital refuses to accept the patient due to not having the services needed/being on diversion/etc., we then suggest once again, the more appropriate hospital.  

I had one patient that was so upset the hospital wouldn't accept her as an ambulance patient, she insisted upon getting out of the ambulance and going in her own vehicle, so they couldn't turn her away.  We tried to explain the situation to her, and she wanted no part of it.  That was her hospital, so that is where she was going to go, regardless of the reason she was being advised to go elsewhere.  Fortunately, that has been the only time I've had that happen.  Everyone else has always agreed to go to the different ER.


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## Bullets (Sep 23, 2011)

My life is easy in this section of NJ. We have a level II in my town with cath lab and stroke facilities. Pretty much every patient goes to this hospital because there isn't a more appropriate facility closer. The next closest HOSPITAL is about 15 minutes north or 20 minutes west. 

So everyone goes to the level II, and the company owns 2 other hospitals in my county and 2 in the county south of me so very few issues with insurance or billing. In fact I have never had a patient raise and issue with our transport destination based on insurance reasons. And I work for a non billing agency so thats never an issue either. 

As far as hospital transfers, every hospital I've been to has dedicated triage areas before they go into a floor or ED proper. We bring then in and put then on the bed immediately and give a report and are out the door. We maybe wait 10 minutes before care is transfered.


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## JJR512 (Sep 23, 2011)

JPINFV said:


> I'm done. If you want to continue living in the fantasy world where insurance doesn't matter and the only thing people use the 911 system is for immediate life threatening conditions, then so be it. The rest of us, who live in the real world, realize that this isn't the case can continue this discussion.
> 
> Oh, and there's power in "why" and "why not," and someone who asks those questions can very easily get a reply along the lines of, "I don't know, why don't we do that?" Viola, the system is changed.


 
How about YOU keep living in YOUR fantasy world of making up **** ok? I never said people only use 911 for immediate life threatening conditions. Or maybe you should learn to read and comprehend before you go popping off on your high horse.

And as for your "oh, and blah blah blah", yeah, no ****. Anyone can answer anything they want to any question they're asked. You're not making any big revelation there.


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## JPINFV (Sep 23, 2011)

JJR512 said:


> How about YOU keep living in YOUR fantasy world of making up **** ok? I never said people only use 911 for immediate life threatening conditions. Or maybe you should learn to read and comprehend before you go popping off on your high horse.



Yet...



JJR512 said:


> The patient called 911 because they believed they  had an emergency need to get to the hospital. If the patient's medical  condition is such that an extra 10, 15, or even 30 minutes in an  ambulance is of no medical signficance, then in my opinion, they don't  really need to be in the ambulance in the first place,



 So, which is it. If 10 minutes doesn't make a difference, then they don't need an ambulance, or are there patients who are legitimately transported by ambulance where 10 minutes doesn't make a difference? You can't have both.


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## jjesusfreak01 (Sep 23, 2011)

medic417 said:


> It is idiotic to transport every caller that requests transport.  This leads to people learning to abuse the system.  All progressive quality systems either have or will soon have a denial of transport guideline.



Wake County is in the very very early stages. We are currently working to sync our triage algorithms with the hospital to see if we can triage patients the same. Once this is done I think at some point people who triage to the lowest level will be encouraged to seek care at an ER or urgent care POV. We already have alternative destination transport through our APP program.


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## usalsfyre (Sep 23, 2011)

JPINFV said:


> So, which is it. If 10 minutes doesn't make a difference, then they don't need an ambulance, or are there patients who are legitimately transported by ambulance where 10 minutes doesn't make a difference? You can't have both.


I'll grant him this, at the basic level with no pain management, cardiac monitoring and ECG acquisition, N/V treatment, inhaled beta agonist ,ect, there's probably not a lot of distinction. At more advanced levels there's a lot more shades of grey.


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## Dpiner42 (Sep 23, 2011)

In my area this is very common. Why? There's a party near the hospital, individual doesn't have a vehicle or money and wants to go - medicade at it's finest. We typically make them sign a form stating if their insurance doesn't cover the bill they may be charged - and by may - i mean they will be charged. They get their ride, sign AMA, and go to the party - get a medicade taxi back home and everything is good. I had one lady respond to the problem of possibly being billed by stating "I will just send the paper to the DSS and they HAVE to take care of it!"


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## dixie_flatline (Sep 23, 2011)

Hey guys... yeah, this got a little out of hand.  

Back to (somewhat) on point - to quote House, _Everyone Lies_.  Why am I going to believe a patient who is insisting on going to a certain hospital because it's "In Network"?  We have enough idiots who somehow know exactly what to say with regards to pain levels and allergies to get the good narcs, so they certainly know how to game the system.  I realize that it's a cynical perspective, and I'm fully aware that 90% of the patients I see are actually pretty straight with me, but I don't like setting precedents.  We don't bill for any EMS services, and have no way to verify anything having to do with insurance.

Some of what JJR said about billing and insurance is a little naive, but not all of his points are off-base.  Our stations are both fairly close to Baltimore and Anne Arundel counties (and his also runs to Laurel in PG county) - if we transport to St Agnes (Baltimore Co) or BWMC (AA Co), we not only put Howard County down an ambulance, we run the distinct risk of getting "stuck" out of county as our neighbors have been known to go to us first to try and keep a "free" extra unit in their county to run as many calls as possible.  It doesn't stop me from transporting out of county - I probably run 60% of the time to HCGH, 35% to St Agnes - but it is something to consider.

As a post-script, I'm an EMT, and fairly pro-active when it comes to things like my own health, and *I'm* not even sure what hospitals in the area are In or Out of network.  (I know how to check on docs through Aetna; never looked up a hospital)


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## usalsfyre (Sep 23, 2011)

Has anyone offered a convincing reason for always transporting to the closest facility that centers on the patient?

What I've seen are a whole host of excuses regarding provider connivence and referring to "the community" rather than the patient that is actually asking for help. I'm sorry but the overstated concern for the community rings a bit hollow seeing as how many of you don't seem to give two hoots about the patients social well being.


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## JJR512 (Sep 23, 2011)

JPINFV said:


> Yet...
> 
> 
> 
> So, which is it. If 10 minutes doesn't make a difference, then they don't need an ambulance, or are there patients who are legitimately transported by ambulance where 10 minutes doesn't make a difference? You can't have both.


 
Earlier you referred to me living in a dream world where people only call 911 if they have a life-threatening emergency. What I wrote indicates that this concept is the ideal, but nowhere in what you quoted do I indicate that it's what I think is truly the case in the real world. This is why I suggested earlier that you improve your reading and comprehension skills. You're seeing things that aren't there. I maintain everything I wrote, _as written_. I'm not responsible for, and will not get drawn into an argument over, your interpretation of what I write. What I mean is right there in black and white, or whatever forum color scheme you're using.


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## EMTPassion (Sep 24, 2011)

IMO if a patient demands transport, even if nothing is actually wrong. Transport the patient. In canada or at least where i'm in training you can not in any circumstances refuse transport if the patient wants to go to the hospital. They get too go, and yes people abuse the system. But what can ya do.


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## medic01 (Sep 24, 2011)

EMTPassion said:


> IMO if a patient demands transport, even if nothing is actually wrong. Transport the patient. In canada or at least where i'm in training you can not in any circumstances refuse transport if the patient wants to go to the hospital. They get too go, and yes people abuse the system. But what can ya do.




I am with you even if it is bull crap that is what we are there for. Half the time they change the story enroute. All we can do is just educate and hopefully make a difference in at least on person's life during our career.


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## Handsome Robb (Sep 24, 2011)

We have the option of CPC for an intoxicated pt. Vitals are WNL but they can't care for themselves PD is coming and taking them to the tank. There's no reason to tie up an ALS resource with a drunk person who requires no medical intervention.

caveat: this is for intoxicated people who are grossly intoxicated, not the transient who wants a ride, there's not much you can do about that situation besides transport.


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## epipusher (Sep 24, 2011)

medic01 said:


> I am with you even if it is bull crap that is what we are there for. Half the time they change the story enroute. All we can do is just educate and hopefully make a difference in at least on person's life during our career.



This is the type of reply I was looking for. It sums up my personal feelings and the majority of my co-workers feelings. It is not our place to judge our patients.


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## medic417 (Sep 25, 2011)

epipusher said:


> This is the type of reply I was looking for. It sums up my personal feelings and the majority of my co-workers feelings. It is not our place to judge our patients.



By refusing transport you are not judging you are educating the patient.  If you say I'm sorry your illness does not require an ambulance then explain where they should seek help you have educated them.  You have also save them or the tax payers money.  

Quit taking the lazy way out by transporting everyone.  Be a medical professional and be honest with the patient.  Honesty sometimes means saying no.


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## epipusher (Sep 25, 2011)

medic417 said:


> By refusing transport you are not judging you are educating the patient.  If you say I'm sorry your illness does not require an ambulance then explain where they should seek help you have educated them.  You have also save them or the tax payers money.
> 
> Quit taking the lazy way out by transporting everyone.  Be a medical professional and be honest with the patient.  Honesty sometimes means saying no.



It's far from laziness. In my experience in the area I work, you will spend more time trying to educate than it would take to just transport. The majority of them have their mind made up way in advance of me showing up. Or it is one of my "frequent flyers" who are going to go regardless of what I or the police on scene may tell them. Even scarier, invoking a policy of educating versus transport can become a very slippery slope.


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## medic417 (Sep 25, 2011)

epipusher said:


> It's far from laziness. In my experience in the area I work, *you will spend more time trying to educate than it would take to just transport*. The majority of them have their mind made up way in advance of me showing up. Or it is one of my "frequent flyers" who are going to go regardless of what I or the police on scene may tell them. Even scarier, invoking a policy of educating versus transport can become a very slippery slope.



So by your statement the lazy way is to transport because it is easier.  Work harder now and smarter by educating, then it will become the easier way as well as the better way for your patients.  Fear of doing what is right is what is holding EMS back.  So get your system on board to start educating patients, including educating by saying no.


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## the_negro_puppy (Sep 25, 2011)

medic417 said:


> By refusing transport you are not judging you are educating the patient.  If you say I'm sorry your illness does not require an ambulance then explain where they should seek help you have educated them.  You have also save them or the tax payers money.
> 
> Quit taking the lazy way out by transporting everyone.  Be a medical professional and be honest with the patient.  Honesty sometimes means saying no.



Some systems/countries don't allow "No". We can do our best to persuade people towards other options though


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## medic417 (Sep 25, 2011)

the_negro_puppy said:


> Some systems/countries don't allow "No". We can do our best to persuade people towards other options though



Thus time to change the protocols.


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## ffemt8978 (Sep 25, 2011)

medic417 said:


> Thus time to change the protocols.



Can't change the protocols until EMS providers are better educated in medicine.


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## medic01 (Sep 25, 2011)

I understand the confusion. In one of the systems I worked thr transporting medic had no athourity even if we where onscene first. The city fire deparment had total scene and pt controle even if they did not ride in. Pretty :censored::censored::censored::censored:ty system. 



usalsfyre said:


> We can't refuse transport. Both cases get transported, with accurate documentation as to the reason for the call.
> 
> I am curious about the "scene control saying get them out of the city". What exactly does that mean? How are transport decisions not up to the transporting medic?


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## medic417 (Sep 25, 2011)

ffemt8978 said:


> Can't change the protocols until EMS providers are better educated in medicine.



Not complicated deciding who needs ambulance transport vs who doesn't.  Anyone not educated well enough needs to be out of EMS.


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## Sasha (Sep 25, 2011)

Sure it is when there are those who believe its only an emergency if its a cool trauma or theyre gasping for breathe. Woman presenting with abd or lower back pain? Just indigestion or stressed muscle

Sent from LuLu using Tapatalk


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## JPINFV (Sep 25, 2011)

medic417 said:


> Not complicated deciding who needs ambulance transport vs who doesn't.  Anyone not educated well enough needs to be out of EMS.



Apparently it's more complicated than you think.

http://www.ncbi.nlm.nih.gov/pubmed/16798145


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## ffemt8978 (Sep 25, 2011)

JPINFV said:


> Apparently it's more complicated than you think.
> 
> http://www.ncbi.nlm.nih.gov/pubmed/16798145



Interesting study...


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## FourLoko (Sep 25, 2011)

I often ask myself why this person needs ambulance transport. Either way, we just do it.


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## usalsfyre (Sep 25, 2011)

The only issue I have with that paper (I actually think the results are probably very valid) is they did not then provide education and repeat to see if the deficiency was easily correctable.


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## Shishkabob (Sep 25, 2011)

JPINFV said:


> Apparently it's more complicated than you think.
> 
> http://www.ncbi.nlm.nih.gov/pubmed/16798145



You're confusing needing an ambulance transport with who needs to be admitted.  Two, sometimes coinciding, but radically different things.



And now I want to see a study for:

Physicians
HEMS nurses
ICU/ED/Med surg nurses.


All with the same tools that EMS has out in the field.


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## medic417 (Sep 25, 2011)

ffemt8978 said:


> Interesting study...



Very flawed study.  Admission to hospital or even ICU does not equal needs an ambulance.


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## usalsfyre (Sep 25, 2011)

Linuss said:


> You're confusing needing an ambulance transport with who needs to be admitted.  Two, sometimes coinciding, but radically different things.
> 
> 
> 
> ...



Really it's not terribly hard with
a good basic assessment. The problem is the majority of paramedics have never been taught anything beyond the ED.


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## JPINFV (Sep 25, 2011)

Linuss said:


> You're confusing needing an ambulance transport with who needs to be admitted.  Two, sometimes coinciding, but radically different things.
> 
> 
> 
> ...




Irrelevant. Paramedics are saying that they, with their current education and tools available, can safely and competently determine who needs to go to the hospital and who doesn't. Furthermore, education and training is vastly more important than anything else.


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## Aidey (Sep 25, 2011)

Did the paramedics in that study know the hospital's ICU admission criteria? In my area the different hospitals have different criteria for ICU admission, so an ICU patient at one hospital may be an acute care unit patient in another.


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## JPINFV (Sep 25, 2011)

Aidey said:


> Did the paramedics in that study know the hospital's ICU admission criteria? In my area the different hospitals have different criteria for ICU admission, so an ICU patient at one hospital may be an acute care unit patient in another.




...yet could only predict 62% of the patients who needed to go to be admitted to either.


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## Shishkabob (Sep 25, 2011)

JPINFV said:


> Irrelevant. Paramedics are saying that they, with their current education and tools available, can safely and competently determine who needs to go to the hospital and who doesn't. Furthermore, education and training is vastly more important than anything else.



No, it is not irrelevant.  The issue at hand is who needs and/or benefits from ambulance transport, not who needs to be admitted for further testing and/or treatment.




And again, until we see the percentages for physicians and nurses under the same circumstances, the 'study' is rather invalid.  No control?  No other variables to see if it's just education or other factors?


Crappy 'study'.


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## JPINFV (Sep 25, 2011)

They don't just admit every patient to a ward.


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## 18G (Sep 25, 2011)

I dont think the study is flawed necessarily. It just needs to be understood and taken into consideration that Paramedics in the field do not have the same tools or lab results to base their decision off of that hospital providers do. 

The study should make specific mention of that limitation and not sound as though Paramedics don't have the assessment capability to accurately make the admission determination. 

If Paramedics had access to imaging and blood work than I think this study would show something completely different. And also, put an RN in the field with limited data and lets see what the same study show's?


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## JPINFV (Sep 25, 2011)

RNs aren't making admission decisions and the decision not to transport a patient could very easily result in a patient who needs to be admitted never making it to the hospital.


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## abckidsmom (Sep 25, 2011)

18G said:


> I dont think the study is flawed necessarily. It just needs to be understood and taken into consideration that Paramedics in the field do not have the same tools or lab results to base their decision off of that hospital providers do.
> 
> The study should make specific mention of that limitation and not sound as though Paramedics don't have the assessment capability to accurately make the admission determination.
> 
> If Paramedics had access to imaging and blood work than I think this study would show something completely different. And also, put an RN in the field with limited data and lets see how the study go's?



I was just trying to think of some of the last few patients I've seen, and I don't think my accuracy would be much better, even given that I've worked in an ICU and on a cardiac floor as an RN.

We just don't get the full picture in the field, we don't get to see how the patient responds to treatment in the ER, and we aren't on the cutting edge of what's possible as a treat and release in the ER.  

That guy who missed dialysis 2 days this week and is now edematous, with abdominal pain and hypertension?  Is he getting admitted or are they going to dialyze him in the ER and send him home?

The guy with the extensive history of diabetic wounds with the copperhead bite?  Are they going to want to continue the IV abx beyond the first 12 hours to preempt the infection that's almost certain to develop?

How about the guy who was woken from sleep with wheezing and rales?  There's nothing on his 12 lead to indicate that it's more than just COPD exacerbation and pneumonia, but what if there is?

I think that even with great assessment skills, you just can't always predict with great accuracy what's going to happen in the patient's course.


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## abckidsmom (Sep 25, 2011)

JPINFV said:


> RNs aren't making admission decisions and the decision not to transport a patient could very easily result in a patient who needs to be admitted never making it to the hospital.



Absolutely.  Making the decision not to transport is often making a permanent decision for patients with regard to accessing health care for their issue.  People really do believe that being seen by a paramedic and "checked out" is useful for something, and if the medic says they're ok, then they roll with that and seek no further care.


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## 18G (Sep 25, 2011)

abckidsmom said:


> I was just trying to think of some of the last few patients I've seen, and I don't think my accuracy would be much better, even given that I've worked in an ICU and on a cardiac floor as an RN.
> 
> We just don't get the full picture in the field, we don't get to see how the patient responds to treatment in the ER, and we aren't on the cutting edge of what's possible as a treat and release in the ER.
> 
> ...



This is why I am always more in favor of transporting to a hospital where the patient can have a workup and be monitored and assessed for more than 15-20mins.


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## usalsfyre (Sep 25, 2011)

The big issue that came out of the paper to me was the fact that medics undertriaged when there should have been significant overtriage.

A lot of it is "BSitis".


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## abckidsmom (Sep 25, 2011)

18G said:


> This is why I am always more in favor of transporting to a hospital where the patient can have a workup and be monitored and assessed for more than 15-20mins.




And those are all examples from just the last week.  There are too many shades of gray for anything more than the most clear-cut, most obvious things to be left at home.  

I find that the more experience I get, the more my gut feeling says to just take them to the hospital in all but the most assinine cases.


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## Shishkabob (Sep 25, 2011)

JPINFV said:


> RNs aren't making admission decisions and the decision not to transport a patient could very easily result in a patient who needs to be admitted never making it to the hospital.



I want to see what their rate would be.  It's the only fair thing if you're going to do a study.




The issue isn't so much saying "You're fine, you don't need to go", it's being able to say "You should still go, but not by ambulance." or offering an alternative destination such as an urgent care clinic instead of always and every time, the ED.


Most people don't need to go by ambulance because there is nothing we will do for them in the ambulance.  Most with minor ailments won't deteriorate between their house and the ED if taking a taxi or bus... or one of the multitude of working vehicles in their driveway, driven by one of the dozen family members standing there staring at us.


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## JPINFV (Sep 25, 2011)

usalsfyre said:


> The big issue that came out of the paper to me was the fact that medics undertriaged when there should have been significant overtriage.
> 
> A lot of it is "BSitis".




...which is why they didn't even bother to report negative predictive value or sensitivity in the abstract. In this case, overtriage and false positives aren't a problem, especially when compared to the issues of undertraige.


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## abckidsmom (Sep 25, 2011)

usalsfyre said:


> The big issue that came out of the paper to me was the fact that medics undertriaged when there should have been significant overtriage.
> 
> A lot of it is "BSitis".



Absolutely.  This is where the typical medic laziness comes in for me.  On the 10th, 18th, or 23rd hour of the shift, these shades of gray are covered by the glaring red flashing light of "I don't wanna do any more work!"

Especially in our area, which has a 2 hour turnaround, minimum, on transports, the chances of getting a refusal go up exponentially during sleeping hours and in the last hours of a shift.


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## usalsfyre (Sep 25, 2011)

I'd actually be VERY curious what the most commonly mistriaged complaint was.


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## usalsfyre (Sep 25, 2011)

abckidsmom said:


> Absolutely.  This is where the typical medic laziness comes in for me.  On the 10th, 18th, or 23rd hour of the shift, these shades of gray are covered by the glaring red flashing light of "I don't wanna do any more work!"
> 
> Especially in our area, which has a 2 hour turnaround, minimum, on transports, the chances of getting a refusal go up exponentially during sleeping hours and in the last hours of a shift.



Very true. I consider myself a good clinician. But at hour 20 of wakefulness, I'm not the same provider as I am at hour 8. 

Which is a reason I hate 24s actually.


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## Shishkabob (Sep 25, 2011)

usalsfyre said:


> Very true. I consider myself a good clinician. But at hour 20 of wakefulness, I'm not the same provider as I am at hour 8.
> 
> Which is a reason I hate 24s actually.



My mom still wonders why we're allowed to do 24 hour shifts.



I, too, despise 24s.


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## usalsfyre (Sep 25, 2011)

Linuss said:


> My mom still wonders why we're allowed to do 24 hour shifts.
> 
> 
> 
> I, too, despise 24s.



Tradition and it requires less personnel.


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## abckidsmom (Sep 25, 2011)

usalsfyre said:


> Tradition and it requires less personnel.



My department staffs 24/7 coverage on a *1 man* engine (yes really- volunteers are counted on highly) and a medic unit with a dozen people at our station.  You can't get more bargain basement than that.

It's an uphill battle, working for improvements in such a system, but it is nice working down the street from home.


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