# Suicidal patient refusal?



## Jim37F (Jul 11, 2017)

So you were dispatched 911 for a suicidal patient. They're A&O x4, GCS 15, they asked someone at the board and care place they live at to call because they're suicidal with a plan to run into traffic.

Pt has a history of bipolar, schizophrenia, and high cholesterol, no known allergies, and is non compliant with meds, doesn't take any, can't even remember their names.

Pt is otherwise calm, cooperative and is requesting to go to the local hospital that has a Psychiatric Emergency Dept to see someone for the suicidal thoughts.


Cut to 3 hours later, you're registered and triaged and sent to the Psych ward. It's the kind of place with the big locked door and you're expected to wait out in their waiting area until they call you in. It's been 3 or so hours, just waiting (which is known to be.....not unusual for this place by other crews).

However, after waiting on the gurney for hours, your patient is starting to get more and more agitated, telling you she wants to walk out and leave stating she's "feeling fine and all better". The main ERs attitude for patient AMAs off EMS gurneys for BLS patients is pretty much "if they're A&O and can stand and walk on their own power without assistance, the exit is down this hall....you need a nurse signature saying you actually brought them in? Here ya go, k thx bye"

So since our SI patient isn't on a legal hold of any kind, isn't being restrained, or anything else....are they free to walk out AMA same as above? Does the fact that they're SI mean we have to keep them from leaving? Is it provider discretion?

(Note, I'm not actually asking for legal advice for a specific situation, the actual patient this scenario is based on who got me curious was actually transferred to the M.D. in the Psych ward.....im curious as to how you would handle the situation in your area in your system under your laws/policies/SOPs/etc)


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## DesertMedic66 (Jul 11, 2017)

Any suicidal patient is placed on a psych hold prior to me transporting to avoid this issue. I have almost been burned before. I also don’t trust PD when they say “oh, we will meet you at the ED and finish the paperwork there” as I have almost been burned with that also (ended up getting our supervisors, PD  Lieutenant, and hospital medical director involved). 

Since you are in the hospital it is their patient now. I would have walked up to the charge nurse and simply stated what was going on and that it is their patient. If they wish to let the patient sign AMA that is on them. I have my signature stating I handed over all patient care to RN Jane.


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## captaindepth (Jul 11, 2017)

Does this patient pose a danger to themselves or others? They stated their plan was to walk into a traffic in an attempt at self harm and now, hours later, they want to walk out of the hospital and out of YOUR care. I believe they have demonstrated themselves to be a risk  to themselves due to their statements (made while sober, alert, and orientated) but also to the public due to wanting to run into traffic. Also the patients diagnosed medical hx is concerning for rapid changes in presentation/combativeness. I think there is enough there to hold the pt against their will under implied consent and I would not let them leave. We have arm restraints permanently affixed to our stretchers, arms go in the restraints, leg and chest belts tightened and they aren't leaving. 

The fact that a patient on an ambulance stretcher, in the care of EMS, would have to wait in a hall for 3 hours is OUTRAGEOUS!!!!! I'd be livid with the ED and I'd let them know it. If the pt continued to escalate in the ED I wouldn't take any immediate action and continue to insist the ED does their job, if they refuse I'd treat the patient right there in front of them. Then I'd start making some phone calls. 

It's a tough situation for sure and easy to arm chair quarterback the call. In reality there are is a lot of situational factors that come into play but I try to remember to do what's best for the patient, and if the patient walks out of that hospital and jumps in front of a bus then I would be destroyed for a multitude of reasons.


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## aquabear (Jul 12, 2017)

This smells like some bush league Harbor General s**t.

Anyways... here in Texas, if they have decisional capacity, aren't on a legal hold or in protective custody, they can sign my refusal form and peace out. Now my partner will be calling for PD/CIT at the same time this is all going down, and they can sort it out.

In your case, I would have just rang the door bell to the Psych ER and tell them what's about to happen with your/their Pt.


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## Tigger (Jul 12, 2017)

We don't really do holds here anymore for scene calls. If you think the patient is suicidal and you want to use some physical/chemical restraint, do so. If the patient puts you in danger, you leave and it becomes an LE issue, not because of SI but because they attempted to harm others. When we transport by ambulance (which at my FT job is rare, but I'll spare everyone my spiel on our community paramedic mental health program), you go right to a bed. We don't hold the wall here anyway. Usually it's in the psych hall, and if it isn't, security will watch them. The attending can then choose to place a hold or not.


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## SpecialK (Jul 12, 2017)

It is being strongly reinforced that this is a medical / ambulance / health issue.  Not a police issue.  Apparently, staff were calling the police a bit too frequently for "help" when it wasn't necessary and the police have been successfully prosecuted for "helping" ambulance personnel (which means restraining people) when they were not legally authorised to do so.  To that end, the police are only  to be requested if the patient is creating imminent danger.

In this scenario, where the patient was taken to ED but wants to walk out ... well, that's up to the hospital to deal with honestly.  I would be happy to get involved assisting them but if they want to do anything then their clinical personnel need to do it.


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## EpiEMS (Jul 12, 2017)

All of the suicidal ideation patients I've ever had have been put on a PD hold ("emergency commitment") either while we were on scene or prior to our arrival. PD will ride with us or follow closely behind. Rarely have I had a need for restraints (chemical or otherwise).

Now, given that this particular patient was not on a hold of any kind, and you've transferred care -- this is on the hospital/RN. (I might try and suggest to the patient that they stick around for the psych ED, though. Not sure if that would backfire?)


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## Akulahawk (Jul 12, 2017)

For the suicidal patient that's not on a hold, that's alert and oriented, that's not combative, if the patient wants to leave, so be it. You have very little (if anything) usually available to legally prevent them from leaving. Simply because they say they're suicidal and have a plan, if they're not on a hold and they're not under arrest, they have the same rights as anyone else does to just up and leave. If the patient becomes combative, that's a different issue. I'll put those people in restraints to prevent injury to myself and to the patient. 

However, in the particular situation in this thread, the patient has been registered, triaged, probably has been seen by a provider to be determined medially clear to go to a mental health unit... if the patient that's not on a hold wants to leave, notify the staff and document who you notified. The patient is now really the hospital's problem and they should have taken the patient off your hands as soon as the patient was deemed OK to go to the mental health unit. Transport within the facility isn't usually an EMS responsibility.


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## hometownmedic5 (Jul 12, 2017)

Wait a minute. You're routinely committed to calls for hours _after you get to the hospital?_ And your employer is ok with that? How in the world are you able to stay in business with UHUs that low?


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## EpiEMS (Jul 12, 2017)

hometownmedic5 said:


> You're routinely committed to calls for hours _after you get to the hospital?_


I believe @Jim37F has indicated in the past that this is common practice (inexplicably, I know) in LA for BLS services


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## hometownmedic5 (Jul 12, 2017)

EpiEMS said:


> I believe @Jim37F has indicated in the past that this is common practice (inexplicably, I know) in LA for BLS services



Amazing. Truly amazing.


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## Jdog (Jul 12, 2017)

hometownmedic5 said:


> Amazing. Truly amazing.



LA/OC EMT here. Can confirm. Longest I've held the wall was 8 hours with a patient on the gurney. Pretty much the majority of my shift.


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## Carlos Danger (Jul 12, 2017)

captaindepth said:


> The fact that a patient on an ambulance stretcher, in the care of EMS, would have to wait in a hall for 3 hours is OUTRAGEOUS!!!!! I'd be livid with the ED and I'd let them know it. If the pt continued to escalate in the ED I wouldn't take any immediate action and continue to insist the ED does their job, if they refuse I'd treat the patient right there in front of them. Then I'd start making some phone calls.



This. The ED keeping a patient waiting and an EMS unit tied up for that long is absolutely unacceptable.


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## hometownmedic5 (Jul 13, 2017)

I'm not even thinking about the patient yet. Yeah, I know I probably should start there, but I can't get past the money part. 

I truly don't get how a company can stay in business racking up a hot two calls per truck per shift. 

Well done Californian EMS, You've done it again...


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## DrParasite (Jul 13, 2017)

In California, the ambulance companies willingly provide free staffing to the hospitals who refuse to staff appropriately, because their EMS crews will monitor the patients until the hospital decides to find them a bed.  This is a common practice (and one that blows my mind too).

Apparently EMTALA doesn't apply to them (the whole once you are on the hospital property, and cross the ER doors, the hospital becomes the responsible party for the patient (http://www.medlaw.com/do-ambulance-jam-ups-at-hospitals-violate-emtala/)



Jim37F said:


> However, after waiting on the gurney for hours, your patient is starting to get more and more agitated, telling you she wants to walk out and leave stating she's "feeling fine and all better". The main ERs attitude for patient AMAs off EMS gurneys for BLS patients is pretty much "if they're A&O and can stand and walk on their own power without assistance, the exit is down this hall....you need a nurse signature saying you actually brought them in? Here ya go, k thx bye"


It's a hospital issue.  if the patient wants to go, the ER won't stop them, and will sign your paperwork accepting that you brought them there, let them go.  It's an EMTALA issue, and I'm sure they could get jammed up for it (but again, california does some..... special things that wouldn't fly elsewhere), but it's not your issue.

You did your job taking them to the hospital.  What the hospital does with your patient isn't your responsibility.


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## DrParasite (Jul 13, 2017)

Oh, and it's not a secret that you can hold the wall for up to 8 hours......:

http://www.pe.com/2015/06/14/rivers...eep-patients-ambulances-waiting-survey-finds/
https://www.ems1.com/ems-management...S-nearly-paralyzed-by-ambulance-delays-at-ER/
http://medicmadness.com/2014/02/holding-the-wall/
http://www.vvdailypress.com/article/20150124/NEWS/150129885

apparently this issue is not isolated to California
http://www.jems.com/articles/2012/06/bed-delays-keep-emsa-medics-hospitals.html
http://www.firehouse.com/news/10501159/emergency-room-overcrowding-making-ambulance-crews-wait
http://www.dailymail.co.uk/health/a...g-long-wait-ambulance-hospital-admission.html


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## hometownmedic5 (Jul 13, 2017)

A routine delay of greater than 30min or a special circumstances delay of greater than an hour would turn my dispatchers and supervisors into an apoplectic nightmare. 

We'll just add this to the seemingly never ending list of things regarding California that make me shake my head...


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## captaindepth (Jul 13, 2017)

Just curious, for you guys out there who have to "hold the wall" with patients on your stretcher do the hospitals give preference to certain agencies? So if numerous agencies are all waiting for a room with the same BLS patient will the ED play favorites with who gets a room first?


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## VentMonkey (Jul 13, 2017)

captaindepth said:


> Just curious, for you guys out there who have to "hold the wall" with patients on your stretcher do the hospitals give preference to certain agencies? So if numerous agencies are all waiting for a room with the same BLS patient will the ED play favorites with who gets a room first?


Nope, patient acuity. Any, and all patients that meet criteria for higher acuity will continuously push the unit back in terms of offloading.

After the higher acuity patients are sorted, they'll typically figure out which low-level patient requires a bed over triage according to the "first come, first serve" motto. Most of us in my area who've been doing it a while know which hospitals want what offloaded into their lobby. You also get to know your MICN's as well as their personalities, and preferences.


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## captaindepth (Jul 13, 2017)

I assumed patient acuity took priority, which is why I was wondering if all patients were the same BLS patient would there be any agency preference. 

The idea of having to wait that long for the hospital assume care of a patient is mind boggling to me. We transport to 12 different hospitals and all of them will have bed assignments (or triage) prior to our arrival. When there is no rooms available they will start filling up hallway beds (report and care are still transferred to a nurse and sometimes a doc upon EMS arrival), once the hallway beds are full they go on ED divert. Its rare we have a patient on our stretcher for more than 5-10 minutes after we arrive in the ED. We are available for the next call as soon as we arrive at the ED with the patient, if we don't get a call we are expected to clear and go back into service in 20 minutes. I think our system would implode if we had hour + wait times in the ED. Crazy.


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## DrParasite (Jul 13, 2017)

So a FD 911 ambulance still waits in line behind an IFT BLS truck?  so an entire first due area is unprotected because the ambulance is still in the ER for hours?  I understand (and agree) that patient acuity is how patients are accepted, but I'm surprised management permits this. At my last agency, we used to give our units 10 minutes to turn over care, 20 if they were really busy.  The agency prior to that, we were available the moment you arrived at the ER (and yes, I was dispatched to another call as I was backing into the ER).

While the issue isn't the nurses being mean or lazy, has anyone filed complaints with CMS over this?  it appears to be an issue with lack of beds, and lack of staffing on the hospital side, and they are using EMS as free help because they don't want to pay for the proper amount of personnel.

And who pays for this?  does the patient get billed wait time, does the hospital get a bill for using EMS to monitor their EMTALA required patients, does the insurance company cover it?  I mean, provider's salaries, additional units called in to cover their area, there are costs incurred by the EMS system, who ends up paying for them?


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## NPO (Jul 13, 2017)

Kern County EMS Directive said:
			
		

> Ambulances should not be used to transport 5150 patients that do not have a medical condition.



Law enforcement will place the patient on a hold on scene and transport to and EPAC (Emergency Psychiatric Assessment Center).

Alternatively, remote area deputies have access to a system that allows telemetry access to a Kern County Mental Health evaluator. 

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## EpiEMS (Jul 13, 2017)

NPO said:


> Law enforcement will place the patient on a hold on scene and transport to and EPAC (Emergency Psychiatric Assessment Center).



I like this idea...but how does law enforcement verify that they're not seeing, say, somebody who's actually having a stroke, or is hypoglycemic, or is...on drugs?


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## NPO (Jul 13, 2017)

EpiEMS said:


> I like this idea...but how does law enforcement verify that they're not seeing, say, somebody who's actually having a stroke, or is hypoglycemic, or is...on drugs?


Paramedic assessment and discression. Most of these patients simply say "I'm feeling suicidal, I need help." That's hardly a stroke or drugs. If the patient requests an ER, is altered, or otherwise seems like they could be having a medical issue, the Ambulance is to take them to the hospital. 

But for the simple patient needing psychiatric help, law enforcement is to handle

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## EpiEMS (Jul 13, 2017)

NPO said:


> Paramedic assessment and discression. Most of these patients simply say "I'm feeling suicidal, I need help." That's hardly a stroke or drugs. If the patient requests an ER, is altered, or otherwise seems like they could be having a medical issue, the Ambulance is to take them to the hospital.
> 
> But for the simple patient needing psychiatric help, law enforcement is to handle
> 
> Sent from my Pixel XL using Tapatalk



Interesting, interesting - so there is no EMS response to most of these calls?


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## NPO (Jul 13, 2017)

EpiEMS said:


> Interesting, interesting - so there is no EMS response to most of these calls?


I can't say how many law enforcement handles without me knowing, but we do respond to a fair number. It's actually not all that common for us to send a patient with law enforcement because unless they specifically request a psych eval, and specifically deny medical aid, they go to the ER. It's usually just the frequent psych patients that know the psych facility by name and request it that go with a LEO. Otherwise, most patients think the ER is the gateway to it, so they ask for an ER.

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## EpiEMS (Jul 13, 2017)

@NPO Gotcha, makes sense.


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## Ensihoitaja (Jul 13, 2017)

captaindepth said:


> We are available for the next call as soon as we arrive at the ED with the patient, if we don't get a call we are expected to clear and go back into service in 20 minutes. I think our system would implode if we had hour + wait times in the ED. Crazy.



Right? How often do you go out at the hospital and get told there's another call for you. I've seen stories like this before and it blows my mind that it's just accepted.


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## Tigger (Jul 13, 2017)

DrParasite said:


> (and yes, I was dispatched to another call as I was backing into the ER).


On bad days here in the city the dispatcher will see you getting close to the hospital on the tracking board and then call you on the radio (before you call destination) to tell you that as soon as you say the word destination they'll be tagging you up to another call.


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## NPO (Jul 13, 2017)

Our County LEMSA just posted a directive to outline how to have ALS hand off to BLS when at the hospital waiting for a bed. 

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## GMCmedic (Jul 13, 2017)

I said it in a thread (might have been this one, and I was only jalf joking when I said it), pin a note to their shirt and go available. 

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## DesertMedic66 (Jul 13, 2017)

GMCmedic said:


> I said it in a thread (might have been this one, and I was only jalf joking when I said it), pin a note to their shirt and go available.
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk


Our county actually allows that now. After 30 minutes on bed delay with a BLS patient we will sit them on a chair and have them hold their paperwork and tell that staff “hey guys, he is sitting here. Bye”


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## hometownmedic5 (Jul 13, 2017)

I fully and completely get that every system is different and you cant use one way of doing things to define what everybody else should be doing everywhere.

That being said, I feel like if for whatever reason I was required to go work in California, it would very seriously make me reconsider whether or not I still wanted to be a paramedic. Holding the wall with patients for hours at a time would drive me up the wall. I'm not certain I could make that adjustment. Maybe if it was all I'd ever known and really really wanted that fire job and would do anything to get it I could suck it up; but being a committed single role guy and having experienced life elsewhere, I just dont think I'd even make it through my first shift before downloading an application for Target just to not have to hold the wall anymore. I get super frustrated when I call an entry note in to the hospital 15 minutes out and they dont have my bed ready and waiting for me(being that 99% of the reason to call in stable nonsense patients is so the hospital can prepare for their arrival). I'd lose my mind by about minute thirty.


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## VentMonkey (Jul 13, 2017)

Eh, sometimes it's a much needed, and welcomed reprieve from turning around and bringing in the same crap over and over. Other times it's all about the individual paramedic and their power of persuasion.

Edit: also, unless any of the people in my county have come from Los Angeles, they have zero idea what "holding a wall" really means. That is the epitome of a fractured healthcare system; a compound fracture.


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## gonefishing (Jul 13, 2017)

VentMonkey said:


> Eh, sometimes it's a much needed, and welcomed reprieve from turning around and bringing in the same crap over and over. Other times it's all about the individual paramedic and their power of persuasion.
> 
> Edit: also, unless any of the people in my county have come from Los Angeles, they have zero idea what "holding a wall" really means. That is the epitome of a fractured healthcare system; a compound fracture.


Amen.

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## NPO (Jul 13, 2017)

hometownmedic5 said:


> I fully and completely get that every system is different and you cant use one way of doing things to define what everybody else should be doing everywhere.
> 
> That being said, I feel like if for whatever reason I was required to go work in California, it would very seriously make me reconsider whether or not I still wanted to be a paramedic. Holding the wall with patients for hours at a time would drive me up the wall. I'm not certain I could make that adjustment. Maybe if it was all I'd ever known and really really wanted that fire job and would do anything to get it I could suck it up; but being a committed single role guy and having experienced life elsewhere, I just dont think I'd even make it through my first shift before downloading an application for Target just to not have to hold the wall anymore. I get super frustrated when I call an entry note in to the hospital 15 minutes out and they dont have my bed ready and waiting for me(being that 99% of the reason to call in stable nonsense patients is so the hospital can prepare for their arrival). I'd lose my mind by about minute thirty.


That sounds more spoiled than gifted. If that post is supposed to make us think that you're paramedicine is better, it doesn't. All it says to me is your hospitals have more beds, more nurses, and doctors that don't admit every patient; essentially a better hospital system. 

Our paramedics arent "less" because we hold the wall. Sometimes the altered dementia patient with no acute illness just doesn't have a place to go. Can't go to the waiting room, and no open beds. What do you propose we do? Lay them on the floor and go back in service?

Your post really left me with a bad taste. Really, holding the wall would make you leave the industry? Are you so spoiled that you cant handle a little inconvenience?

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## gonefishing (Jul 13, 2017)

NPO said:


> That sounds more spoiled than gifted. If that post is supposed to make us think that you're paramedicine is better, it doesn't. All it says to me is your hospitals have more beds, more nurses, and doctors that don't admit every patient; essentially a better hospital system.
> 
> Our paramedics are "less" because we hold the wall. Sometimes the altered dementia patient with no acute illness just doesn't have a place to go. Can't go to the waiting room, and no open beds. What do you propose we do? Lay them on the floor and go back in service?
> 
> ...


Maybe we could get the hospitals to invest in a ball pit?

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## Jdog (Jul 14, 2017)

DrParasite said:


> So a FD 911 ambulance still waits in line behind an IFT BLS truck?  so an entire first due area is unprotected because the ambulance is still in the ER for hours?  I understand (and agree) that patient acuity is how patients are accepted, but I'm surprised management permits this. At my last agency, we used to give our units 10 minutes to turn over care, 20 if they were really busy.  The agency prior to that, we were available the moment you arrived at the ER (and yes, I was dispatched to another call as I was backing into the ER).
> 
> While the issue isn't the nurses being mean or lazy, has anyone filed complaints with CMS over this?  it appears to be an issue with lack of beds, and lack of staffing on the hospital side, and they are using EMS as free help because they don't want to pay for the proper amount of personnel.
> 
> And who pays for this?  does the patient get billed wait time, does the hospital get a bill for using EMS to monitor their EMTALA required patients, does the insurance company cover it?  I mean, provider's salaries, additional units called in to cover their area, there are costs incurred by the EMS system, who ends up paying for them?



The thought of getting a call before clearing is insane. In LA, you don't know how long it's going to be once you step foot in the ER. If you have an ALS patient, with any luck, you get a bed right away. With a BLS patient, good luck. You could be stuck for hours. Also, the ambulance company absorbs this cost, since they're paying the EMTs hourly wages for holding the wall plus opportunity costs of that unit not being able to run calls during that time.


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## gonefishing (Jul 14, 2017)

Jdog said:


> The thought of getting a call before clearing is insane. In LA, you don't know how long it's going to be once you step foot in the ER. If you have an ALS patient, with any luck, you get a bed right away. With a BLS patient, good luck. You could be stuck for hours. Also, the ambulance company absorbs this cost, since they're paying the EMTs hourly wages for holding the wall plus opportunity costs of that unit not being able to run calls during that time.


But thats where the LA wait time charge comes in at $75 every 15 minutes.

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## Jdog (Jul 14, 2017)

gonefishing said:


> But thats where the LA wait time charge comes in at $75 every 15 minutes.
> 
> Sent from my SM-G920P using Tapatalk


???
I've definitely never heard of this and can't find anything on LA county's website.


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## gonefishing (Jul 14, 2017)

Jdog said:


> ???
> I've definitely never heard of this and can't find anything on LA county's website.


Now its $100 every 30 minutes.
	

	
	
		
		

		
			





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## Jdog (Jul 14, 2017)

gonefishing said:


> Now its $100 every 30 minutes.
> 
> 
> 
> ...



But... I don't think said person has a choice whether to "request" us to wait. It's not like we can just dump the patient in the hallway? But if so, I didn't realize this was a thing. Interesting, thanks.


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## gonefishing (Jul 14, 2017)

Jdog said:


> But... I don't think said person has a choice whether to "request" us to wait. It's not like we can just dump the patient in the hallway? But if so, I didn't realize this was a thing. Interesting, thanks.


Yea.  Alot of paper tickets use to have a check box.  Or that's why most places ask that after 20 minutes you give an update so they can start the clock at the 30 mark to ensure they bill properly.  Clock doesn't stop until on your electronic pcr you mark tx of care.  On paper you had to write down that time.  This all goes to the pt or the pt's insurance.

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## Jdog (Jul 14, 2017)

gonefishing said:


> Yea.  Alot of paper tickets use to have a check box.  Or that's why most places ask that after 20 minutes you give an update so they can start the clock at the 30 mark to ensure they bill properly.  Clock doesn't stop until on your electronic pcr you mark tx of care.  On paper you had to write down that time.  This all goes to the pt or the pt's insurance.
> 
> Sent from my SM-G920P using Tapatalk



Ahh, that makes sense. Yeah, we get a status request after 20 minutes and mark tx of care time on our epcr. Thanks for the info. I thought our company just eats the cost of us having to the hold wall.


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## gonefishing (Jul 14, 2017)

Jdog said:


> Ahh, that makes sense. Yeah, we get a status request after 20 minutes and mark tx of care time on our epcr. Thanks for the info. I thought our company just eats the cost of us having to the hold wall.


Not at all.  That's all cash.  Not as much as a run but still a pretty good amount of cash for doing nothing.  It's more than paying for you and your partners wage per hour.

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## hometownmedic5 (Jul 14, 2017)

Nowhere did i say im a better paramedic, nor that my organization is superior; but I can unequivocally state my system runs better.

If you think expecting to clear a call in less than an hour from arrival at the back doors makes me spoiled, then I simply don't know what to say to you. I think expecting a crew to hold the wall for hours on end due to a broken healthcare system is absolutely unreasonable, but we're all walking our own path, so you do you.

And yes, if I had no choice but to work in such a system or do something else, I would seek out career alternatives.


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## gonefishing (Jul 14, 2017)

hometownmedic5 said:


> Nowhere did i say im a better paramedic, nor that my organization is superior; but I can unequivocally state my system runs better.
> 
> If you think expecting to clear a call in less than an hour from arrival at the back doors makes me spoiled, then I simply don't know what to say to you. I think expecting a crew to hold the wall for hours on end due to a broken healthcare system is absolutely unreasonable, but we're all walking our own path, so you do you.
> 
> And yes, if I had no choice but to work in such a system or do something else, I would seek out career alternatives.


I think more or less what he was pointing out was that your fortunate that your system has more beds and more staff to fit your population needs where as here in California, the population has skyrocketed in certain areas out doing the supply.  Almost like economics 101 supply and demand.  You have say 2 hospitals both with 10 er beds equaling out to 20.  The ppolulation is 8, it grows to 18 in a short period of time.  The hospitals can still manage.  The population grows to 60 later that year, you still have 20 beds for that population of 60 with enough nursing staff at minimum.  Population doubles, you now have no where near enough staff, not enough beds, the supply line (ambulances) clog up and their for the production line like in a factory is held up.  That's the real issue.  The population is growing faster than what the resources in place can keep up with or change with.

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## luke_31 (Jul 14, 2017)

Gonefishing hits the nail on the head. A lot of the system issues is the rapid growth of the patient population, without a corresponding growth in the hospital capacity. Which happens for a multitude of reasons cost being a big one.


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## DrParasite (Jul 14, 2017)

gonefishing said:


> I think more or less what he was pointing out was that your fortunate that your system has more beds and more staff to fit your population needs where as here in California, the population has skyrocketed in certain areas out doing the supply.  Almost like economics 101 supply and demand.  You have say 2 hospitals both with 10 er beds equaling out to 20.  The ppolulation is 8, it grows to 18 in a short period of time.  The hospitals can still manage.  The population grows to 60 later that year, you still have 20 beds for that population of 60 with enough nursing staff at minimum.  Population doubles, you now have no where near enough staff, not enough beds, the supply line (ambulances) clog up and their for the production line like in a factory is held up.  That's the real issue.  The population is growing faster than what the resources in place can keep up with or change with.


Waving the BS flag as hard as I can!!!!!

1) California is not the densest state in the union.  In fact, the top 4 densest counties in the US aren't in California (they are all in NYC).  Los Angeles might be the largest county by population, but that's spread over 4,000 square miles.  When you go into densest cities in the US, Los Angeles isn't even in the top 10 (but San Francisco is).  And you don't hear about people in NY, NJ, Massachusetts, Pennsylvania, DC or Virginia ever holding the wall for hours (that's the top 10 btw).  So the argument that California's population has skyrocketed is crap, because populations in every metro area has skyrocketed, but only California has type of system and accepts this issues as acceptable.

2) I don't doubt that the hospitals need more beds, more nurses, and more staff.   So what's stopping them?  There is obviously a need.  If the hospitals haven't keep up with demand, than they need new administration to actually move forward and expand.  Random surges happen to everyone, but if you are constantly in a surge mode, than that's not a surge, that's normal operations.  If EMS kept the same number of ambulances that they had in the 90s, with the growing call volume, would that be considered acceptable?  so why is it acceptable that the hospitals haven't grown?  If other hospitals have been able to grow, maybe California hospitals needs to learn how to budget and do long term planning?  there are poor areas everywhere, so the argument of "well we have no money" is crap, because they still find ways to fund expansions (they are called capital investments).

3) this whole system is a hospital issue, and EMS shouldn't be providing free labor to the hospital.  I know of one agency that actually sent the hospital a bill for all the time holding the wall.  Administration didn't like it, and did complain, but they provided a service for the hospital, and they shouldn't operate free of charge.  I'm surprised more agencies haven't done that.

4) I agree with @hometownmedic5 , I wouldn't work in a system where I had to hold a wall, regardless of if I have a BS patient or not.  In fact, I would probably start harassing the nurses after the 30 minute mark until they both threw me out of the ER and called me boss and complained, at which point his response should be "well, if you gave him a bed, he would leave you alone, and he could get back to doing the job I'm paying him to do, instead of him doing the job that you are paid to do."



gonefishing said:


> Now its $100 every 30 minutes.


IIRC, wait time gets billed directly to the patient, as the insurance company won't pay it. 

and that was exactly what I was wondering, maybe if enough patient's were billed, and then complained about the bills to the hospitals (who are the cause of them receiving this bills), they would improve their system.  I don't like billing the patient for a hospital issue, but I like having the company eat the cost even less, as it contributes to why EMS gets paid so poorly, because they are stuck in the ERs not making money for their companies and costing them the hourly rate.


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## gonefishing (Jul 14, 2017)

DrParasite said:


> Waving the BS flag as hard as I can!!!!!
> 
> 1) California is not the densest state in the union.  In fact, the top 4 densest counties in the US aren't in California (they are all in NYC).  Los Angeles might be the largest county by population, but that's spread over 4,000 square miles.  When you go into densest cities in the US, Los Angeles isn't even in the top 10 (but San Francisco is).  And you don't hear about people in NY, NJ, Massachusetts, Pennsylvania, DC or Virginia ever holding the wall for hours (that's the top 10 btw).  So the argument that California's population has skyrocketed is crap, because populations in every metro area has skyrocketed, but only California has type of system and accepts this issues as acceptable.
> 
> ...


Yes true as state as a whole population is not the highest BUT certain once small town areas have seen population booms in a small short period of time and or more people are using the ED as their physician.  I agree hospitals need to higher more staff, stop using ems as free labor.  Their is an exception to the wait time fee being passed to the patient.  Such insurance companys as Kaiser Permanente do NOT pass the cost to the patient.  I worked with a company that held that contract and kp gladly paid the fee.  By the way, we also have a nursing shortage.

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## GMCmedic (Jul 14, 2017)

DesertMedic66 said:


> Our county actually allows that now. After 30 minutes on bed delay with a BLS patient we will sit them on a chair and have them hold their paperwork and tell that staff “hey guys, he is sitting here. Bye”


Maybe more people should start doing that and they will get the point. 

I have a big issue with wait times being billed to the patient. They would be better off  if you found them a chair. 

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## gonefishing (Jul 14, 2017)

GMCmedic said:


> Maybe more people should start doing that and they will get the point.
> 
> I have a big issue with wait times being billed to the patient. They would be better off  if you found them a chair.
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk


But not every patient can sit in a chair lol what about your bed confined geriatric with a low hemoglobin that was sent to the ED? 

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## DesertMedic66 (Jul 14, 2017)

GMCmedic said:


> Maybe more people should start doing that and they will get the point.
> 
> I have a big issue with wait times being billed to the patient. They would be better off  if you found them a chair.
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk


What’s worse is that by the county we are given that right but our company policies do not allow us to do it.


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## GMCmedic (Jul 14, 2017)

gonefishing said:


> But not every patient can sit in a chair lol what about your bed confined geriatric with a low hemoglobin that was sent to the ED?
> 
> Sent from my SM-G920P using Tapatalk


Lay them in 3 chairs? 

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## DrParasite (Jul 14, 2017)

still waving the BS flag


gonefishing said:


> Yes true as state as a whole population is not the highest BUT certain once small town areas have seen population booms in a small short period of time and or more people are using the ED as their physician.


 this happens all over, it's not limited to California.  And I didn't mention total state numbers (with California would lead, because it is the largest geographic state in the US), that was only county and city.  That's why I referenced population density, because size is all relative, but density is constant (how many people do you have in a square mile, etc).  And the two densest cities in the US are Gutenberg, Union City, West New York, and Bayonne, all in Hudson County NJ (and they don't have nearly the issues with hospital wall time that you are describing).  New York City isn't even in the top 5





gonefishing said:


> By the way, we also have a nursing shortage.


By the way, there is a nursing shortage everywhere.   Actually, that's not true; many hospitals don't want to hire new grads, or pay them well, or give them the support to do their jobs, so they don't want to work for ****ty places (nationwide, not just California).  Maybe if they staffed more nurses per shift and didn't run them into the ground they wouldn't have their supposed "nursing shortage" (which was made up by the nursing unions and nursing schools, not by the general public, unless they are taking the word from those two biased groups).

BTW, we have a paramedic shortage in the rest of the world, but that doesn't mean you can have the FD babysitting for an hour or two until the ambulance shows up (well, they don't have enough units, because of population growth and they haven't increased staffing or pay in 20 years....)


GMCmedic said:


> I have a big issue with wait times being billed to the patient. They would be better off  if you found them a chair.


I agree; it should be billed to the entity causing the delay, in this case, the hospital.   They are causing the costs to be incurred by the ambulance service, so unless they are forced to pay for it, they are in no position to even try to fix this obviously broken system



gonefishing said:


> But not every patient can sit in a chair lol what about your bed confined geriatric with a low hemoglobin that was sent to the ED?


Your right: the hospital should get them a bed..  you can put them in triage if they need to be (if they are considered low priority), but having the ambulance babysit them isn't helping anyone except for the hospital in not doing their job.

Bottom line, it's a hospital problem, and other urban area have experienced similar usage surges in the last 20 years, but they don't have nearly the amount of wall time that is both common and accepted in California  If you are ok with it, fine, but I know I wouldn't.


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## EpiEMS (Jul 14, 2017)

gonefishing said:


> , the population has skyrocketed in certain areas out doing the supply. Almost like economics 101 supply and demand.





DrParasite said:


> only California has type of system and accepts this issues as acceptable.



I have to wonder if the main cause isn't demand, but supply - artificial supply restrictions like certificate of need laws, laws restricting practitioners from moving across state lines, etc.



gonefishing said:


> By the way, we also have a nursing shortage.



As @DrParasite said, that's not strictly true...a shortage of X means we can't get any more of X at *any price (wage)*.


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## Bullets (Jul 14, 2017)

Your hospitals dont have a triage area you can put patients on a bed? 

Our 30 room ER has a triage area which has 20 beds and 10 recliners, 2 nurses and 2 techs. EMS gives report to triage and puts them on a bed and hospital sorts it our from there. Even on busy busy days its no more than 20 minutes waiting for report.


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## Jdog (Jul 14, 2017)

Bullets said:


> Your hospitals dont have a triage area you can put patients on a bed?
> 
> Our 30 room ER has a triage area which has 20 beds and 10 recliners, 2 nurses and 2 techs. EMS gives report to triage and puts them on a bed and hospital sorts it our from there. Even on busy busy days its no more than 20 minutes waiting for report.



I have been to probably ~40 EDs in the LA/OC area and have never seen a waiting room with beds/recliners.


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## Akulahawk (Jul 16, 2017)

gonefishing said:


> By the way, we also have a nursing shortage.





DrParasite said:


> By the way, there is a nursing shortage everywhere. Actually, that's not true; many hospitals don't want to hire new grads, or pay them well, or give them the support to do their jobs, so they don't want to work for ****ty places (nationwide, not just California).


Actually guys, there really _isn't_ a nursing shortage. This is actually cyclical and right now we're on the downslope into a "shortage" but we won't see it for probably another 5 years or so. Why do I say this? Nurses age. If you want to know where any nursing shortage really _is_ if it's anywhere, it's in the supply of experienced nurses. The cost of travelers may actually be less than training/orienting a new grad (and there's lots of new grads) over the course of a year.


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## bakertaylor28 (Aug 5, 2017)

In reality, whats probably going on, is that they have an issue with beds- a certain number of beds are reserved for holds, and this patient doesn't yet have a hold (why not is beyond me.)  Normally when you mention the words "patient dumping" and "complaint" in an obscure way, they get up off their cans and get YOU out of there, because even if it's not realistic, the terminology scares hospital providers because of the corporate financial implications behind it.


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## MonkeyArrow (Aug 5, 2017)

bakertaylor28 said:


> Normally when you mention the words "patient dumping" and "complaint" in an obscure way, they get up off their cans and get YOU out of there, because even if it's not realistic, the terminology scares hospital providers because of the corporate financial implications behind it.


Don't advocate being obnoxious. EDs don't like having people waiting/holding the wall any more than you do. Plus, I don't know where you work, but at my ER, if you brought that up, we would laugh profusely and go on about our day.


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## DesertMedic66 (Aug 5, 2017)

bakertaylor28 said:


> Normally when you mention the words "patient dumping" and "complaint" in an obscure way, they get up off their cans and get YOU out of there, because even if it's not realistic, the terminology scares hospital providers because of the corporate financial implications behind it.


If you do that I imagine the hospitals must hate you. If I start lying to the hospital I can easily say I will get complaints filed against me and will be on the hospitals **** list which means they will not help me out in anyway or authorize me to use medications for issues that are out of my protocols.


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## Jim37F (Aug 5, 2017)

Well besides the fact that the problem seems more like there's always 3 times as many people waiting as there are beds at the hospital (because people for some reason prefer to come to the ER for every little scrape, bump, bruise, fever, med refill, stomach ache, etc etc)

Plus the Psych ER in question from the original scenario is not part of the normal ER at that hospital. You go into the main ER, get triaged (and for this patient that included a Physician talking to her) while still on the gurney in the hallway....then they send you down the hall to the Psych ER which is a completely different area, so talking to the ER Charge Nurse would have done precisely squat (for those answers that mentioned that) as it's not part of the ER, oh and the staff inside keeps the door locked, you can't go inside to talk to their charge nurse without knocking and waiting for them to come out (which sometimes takes several minutes....."hurry" is not a concept they employ there)

It's a known phenomenon there that the Psych ER routinely takes an hour+ upon arrival.....no friggin clue why that is, but it is. It's bad enough to the point where all you have to do is say you were sent there and other crews are automatically "Ouch, I'm sorry....how bad?"


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## Chris07 (Aug 6, 2017)

My colleagues and I used to have a running joke at one of our area hospitals that the yellower your pants were, the faster you'd get a bed. While it didn't happen all the time, it happened frequently enough that we began to notice some apparent favoritism towards to local city FD when it came to grabbing the next available bed.

Holding the wall in the LA area (and even throughout a lot of CA) for over an hour+, as stated many many times above, is not just common practice, its expected. The pressure for change isn't going to come from the ambulance companies. Yes, they're potentially losing money while their crews wait in the hallways, yet I don't believe ANY LA area company wishes to upset their potential client hospitals by starting noise about wait times. There's a lot of butt kissing involved in LA area ambulance operations, and holding the wall like a good little boy at the expense of your bottom line is all a part of the game.

Psych facilities are in fact among the worse in regards to wait times. Silverlake anyone? If you've worked in LA for a significant amount of time, I'm sure you've heard or experienced a Silverlake psych story.


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## DesertMedic66 (Aug 6, 2017)

Chris07 said:


> Silverlake anyone? If you've worked in LA for a significant amount of time, I'm sure you've heard or experienced a Silverlake psych story.


Oh god. That’s a name I haven’t heard in a long time and I am thankful for that. Last time I was there I was holding the wall for only 3 hours.


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## bakertaylor28 (Aug 7, 2017)

MonkeyArrow said:


> Don't advocate being obnoxious. EDs don't like having people waiting/holding the wall any more than you do. Plus, I don't know where you work, but at my ER, if you brought that up, we would laugh profusely and go on about our day.


I'm sure you would right up until you had federal agents in the facility over it within a week or two. Patient Dumping is a federal criminal offense that the FBI investigates, and last time I checked hospital administrators don't like people seeing federal agents walking up and down the halls of the facility. Its bad PR.


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## bakertaylor28 (Aug 7, 2017)

DesertMedic66 said:


> If you do that I imagine the hospitals must hate you. If I start lying to the hospital I can easily say I will get complaints filed against me and will be on the hospitals **** list which means they will not help me out in anyway or authorize me to use medications for issues that are out of my protocols.



Yep. They all pretty much hate me, because I don't do red tape well. In fact I'm deathly allergic to it. Babysitting a psych patient does NOT fall under the job description of Emergency Medicine. Thats what RNs are for. Now, if they want to pay me RN pay, I'm not going to complain so much, but so far I've yet to see the money. As for double crossing me- probably not something they want to do considering exactly whom it is I'm married to... Unless that is...of course...you like getting traffic tickets...


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## DesertMedic66 (Aug 7, 2017)

bakertaylor28 said:


> Yep. They all pretty much hate me, because I don't do red tape well. In fact I'm deathly allergic to it. Babysitting a psych patient does NOT fall under the job description of Emergency Medicine. Thats what RNs are for. Now, if they want to pay me RN pay, I'm not going to complain so much, but so far I've yet to see the money. As for double crossing me- probably not something they want to do considering exactly whom it is I'm married to... Unless that is...of course...you like getting traffic tickets...


And with that attitude I bet you are well liked by everyone you work with. Also the “I’m married to so and so” usually doesn’t work and just makes you sound like an ***.


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## Jim37F (Aug 7, 2017)

Yeah except caring for BLS patients (whether that's a Psych or minor trauma or whatever) until the transfer of care is complete IS in the job description.....

And you're the one saying we should dump patients in the hallways without proper transfer of care because "I'm not getting nurse pay, and I'm entitled because my spouse will hunt down people who annoy me on my whim".....gee which one sounds like it would receive attention from investigators, that or the hospital that simply doesn't have the capacity to take over your patient at that moment and has you wait..? Hmm....


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## MonkeyArrow (Aug 7, 2017)

bakertaylor28 said:


> I'm sure you would right up until you had federal agents in the facility over it within a week or two. *Patient Dumping is a federal criminal offense that the FBI investigates*, and last time I checked hospital administrators don't like people seeing federal agents walking up and down the halls of the facility. Its bad PR.


Source for the bolded? And federal law simply says that no hospital can intentionally send patients away to another hospital without appropriate stabilization and treatment within that hospital's means. Having you hold the wall to wait for a bed is not "patient dumping" nor a federal crime.


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## DrParasite (Aug 7, 2017)

bakertaylor28 said:


> Normally when you mention the words "patient dumping" and "complaint" in an obscure way, they get up off their cans and get YOU out of there, because even if it's not realistic, the terminology scares hospital providers because of the corporate financial implications behind it.


That might scare the nursing administration, but I can assure you most of the staff nurses aren't intimidated by an EMT or paramedic with an over-inflated ego.



bakertaylor28 said:


> I'm sure you would right up until you had federal agents in the facility over it within a week or two. Patient Dumping is a federal criminal offense that the FBI investigates, and last time I checked hospital administrators don't like people seeing federal agents walking up and down the halls of the facility. Its bad PR.


So call them.  Let the FBI investigate, if you indeed believe that a crime has been committed.  In fact, I would argue that if you don't call the FBI, you are actually contributing to the problem, because you are knowingly allowing this crime to be committed, and patients are suffering for it.


bakertaylor28 said:


> Yep. They all pretty much hate me, because I don't do red tape well. In fact I'm deathly allergic to it.


 Aren't you paid by the hour?  so what do you care?


bakertaylor28 said:


> Babysitting a psych patient does NOT fall under the job description of Emergency Medicine. Thats what RNs are for. Now, if they want to pay me RN pay, I'm not going to
> complain so much, but so far I've yet to see the money


yes you will.  you like to complain.  they could double your pay and you would still complain.


bakertaylor28 said:


> As for double crossing me- probably not something they want to do considering exactly whom it is I'm married to... Unless that is...of course...you like getting traffic tickets...


let me guess... your married to a patrolman?  I'm sure your spouse has nothing better to do than give tickets to hospital staff because they pissed you off.  I would love to know to hear what the Sgt thinks of their actions... as well as the internal affairs officers who receive the complaint that your spouse is targetting and harassing hospital personnel for no good reason....

and newsflash.... Most people in this world aren't scared of traffic tickets.....

Don't get me wrong, I think holding the wall for an hour is absurd, and I have pissed off my share of hospital employees when I notify my supervisor, and the decision is made by my administraion that we can't transport there because they are overwhelmed, but you sound like a royal jackass, and I would hate to work in the same city as you.  In fact, I am pretty sure with an attitude like yours, you would be sent do the back of the line, and ever new ambulance would go in front of you (after all, if you have a stable psych patient, it's not like they are going to get crazier....)



DesertMedic66 said:


> If you do that I imagine the hospitals must hate you. If I start lying to the hospital I can easily say I will get complaints filed against me and will be on the hospitals **** list which means they will not help me out in anyway or authorize me to use medications for issues that are out of my protocols.


What does your medical director thing of you using medications that are outside of your protocols?


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## DesertMedic66 (Aug 7, 2017)

DrParasite said:


> What does your medical director thing of you using medications that are outside of your protocols?


Not medications that are out of my scope but medications that are not listed as treatment options for a complaint. If we get approval by the base hospital physician then there is no issue. 

For example: Mag isn’t listed in the protocols for asthma, glucagon isn’t listed for esophageal obstruction, push dose pressors isn’t listed, pain management for anything aside from an isolated extremity injury isn’t listed. If I get approval from the base hospital’s physician then it is out of the hands of my medical director. Heck, I can’t even tell you what hospital our medical director works at.


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## bakertaylor28 (Aug 7, 2017)

Jim37F said:


> Yeah except caring for BLS patients (whether that's a Psych or minor trauma or whatever) until the transfer of care is complete IS in the job description.....
> 
> And you're the one saying we should dump patients in the hallways without proper transfer of care because "I'm not getting nurse pay, and I'm entitled because my spouse will hunt down people who annoy me on my whim".....gee which one sounds like it would receive attention from investigators, that or the hospital that simply doesn't have the capacity to take over your patient at that moment and has you wait..? Hmm....



What I'm not clear about in the first place  is how a suicidal pt. is a BLS pt. in the first place- Our local protocol and scope of practice designates suicidal / homicidal pts. as ALS pts because of the increased chance of needing chemical restraint, which requires both an EMT-P and also requires MC clearance in certain situations... eh, but I suppose scope of practice is different in every state  

That said, Pt. dumping law also states that if a facility is not capable of completing transfer of the pt. within a "reasonable time" that facility must stabilize the pt.  transfer the pt. to a facility that is capable of receiving the pt. immediately. Per technicality of DSM-IV a suicidal / homicidal pt. is NEVER considered stable absent the initiation of the appropriate definitive psychiatric medical  interventions, which are beyond the skill set of EMS.


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## bakertaylor28 (Aug 7, 2017)

DesertMedic66 said:


> Not medications that are out of my scope but medications that are not listed as treatment options for a complaint. If we get approval by the base hospital physician then there is no issue.
> 
> For example: Mag isn’t listed in the protocols for asthma, glucagon isn’t listed for esophageal obstruction, push dose pressors isn’t listed, pain management for anything aside from an isolated extremity injury isn’t listed. If I get approval from the base hospital’s physician then it is out of the hands of my medical director. Heck, I can’t even tell you what hospital our medical director works at.



This sort of thing is WHY our MC is separate and distinct from the receiving facility. Our system doesn't allow the receiving facility to dictate treatment UNTIL they have formal custody of the patient. We give them the heads up on what they have coming, but thats about it. Issues involving prehospital treatment always goes through OLMC.


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## bakertaylor28 (Aug 7, 2017)

DrParasite said:


> That might scare the nursing administration, but I can assure you most of the staff nurses aren't intimidated by an EMT or paramedic with an over-inflated ego.
> 
> So call them.  Let the FBI investigate, if you indeed believe that a crime has been committed.  In fact, I would argue that if you don't call the FBI, you are actually contributing to the problem, because you are knowingly allowing this crime to be committed, and patients are suffering for it.
> Aren't you paid by the hour?  so what do you care?
> ...



I am a jackass when it comes to that kind of thing, because it most usually means that someone, somewhere, isn't getting up off their can and doing their job, and consequently making my job more difficult than it really needs to be.  I take personal offense to that kind of work ethic. Oh, but that's right in this day and age we don't HAVE work ethics anymore that go BEYOND the bare minimal required. I guess I get this personality trait from working in a hen house. :-D

Of course, then again, I'm the kind of guy that will stop in the middle of the street, hit the lights,  and block traffic for at least 15 minutes  on a mundane run because some "jackass" parked in the fire lane.


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## GMCmedic (Aug 7, 2017)

bakertaylor28 said:


> What I'm not clear about in the first place  is how a suicidal pt. is a BLS pt. in the first place- Our local protocol and scope of practice designates suicidal / homicidal pts. as ALS pts because of the increased chance of needing chemical restraint, which requires both an EMT-P .



By this logic, every patient is ALS because of the chance of cardiac arrest requiring a paramedic to intervene.


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## VentMonkey (Aug 7, 2017)

Can we just stop with the shenanigans already? 

@Chimpie, @MMiz this @bakertaylor28 person clearly seems to be posting solely for the purpose of being spiteful, argumentative, makes absolutely no sense with his random rants, and has contributed nothing useful to this forum.

If this is not trolling, I don't now what is.

-Vent.


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## bakertaylor28 (Aug 7, 2017)

GMCmedic said:


> By this logic, every patient is ALS because of the chance of cardiac arrest requiring a paramedic to intervene.
> 
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk



hrmnn, how do you figure- paroxysmal cardiac arrest isn't all that common in the grand scheme of things, as compared to the significant  chance that a psych pt. is probably going to become combative. (usually because things like significant  EtOH intoxication, etc. tend to be co-morbid in these types of situations.) Of course I'm in favor of training the EMT-I's  to use certain drugs that fall in situations that are most usually going to fall outside ACLS implications. This whole business of allowing the intermediates to obtain IV access and then use it for nothing but fluids is, to me, a rather ignorant approach- as it makes the skill substantially less useful under practical scenarios.


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## GMCmedic (Aug 7, 2017)

bakertaylor28 said:


> hrmnn, how do you figure- paroxysmal cardiac arrest isn't all that common in the grand scheme of things, as compared to the significant  chance that a psych pt. is probably going to become combative. (usually because things like significant  EtOH intoxication, etc. tend to be co-morbid in these types of situations.)


Because any patient that needs an ambulance is at a higher risks for cardiac arrest. 

See how anecdotal evidence works? 

Id argue that in my experience, more patients have spontaneously coded than those that up and decided to be combative. 

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## gonefishing (Aug 7, 2017)

Wheres the mods? Usually when im battling a troll place is shut down by now?

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## bakertaylor28 (Aug 7, 2017)

GMCmedic said:


> Because any patient that needs an ambulance is at a higher risks for cardiac arrest.
> 
> See how anecdotal evidence works?
> 
> ...



I'd agree with that- which is why, personally,  I think the policy is poorly written.  But I suspect political influence goes into these things.



gonefishing said:


> Wheres the mods? Usually when im battling a troll place is shut down by now?
> 
> Sent from my SM-G920P using Tapatalk



I've given my opinion, and I'm sorry you didn't like it.  I've said pretty much all I have to say on the subject, and hence that point of conversation has ended as far as I'm concerned, unless someone else has something to add. But last time I checked, having an opinion wasn't trolling.


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## gonefishing (Aug 7, 2017)

bakertaylor28 said:


> I'd agree with that- which is why, personally,  I think the policy is poorly written.  But I suspect political influence goes into these things.
> 
> 
> 
> I've given my opinion, and I'm sorry you didn't like it.  I've said pretty much all I have to say on the subject, and hence that point of conversation has ended as far as I'm concerned, unless someone else has something to add. But last time I checked, having an opinion wasn't trolling.


No comment.  I don't need to go to the penalty box today.

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## MonkeyArrow (Aug 7, 2017)

@bakertaylor28 but you seemed to ignore my response to your post earlier. Where is your source that holding the wall until a bed becomes available is a violation of federal law that the FBI will investigate?


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## Tigger (Aug 7, 2017)

I'm not really sure what the community is looking for here. If you don't agree with some content, say so. Or say nothing. That should end the conversation pretty quick.

Some arguments cannot be won, even if you're right.


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## bakertaylor28 (Aug 7, 2017)

MonkeyArrow said:


> @bakertaylor28 but you seemed to ignore my response to your post earlier. Where is your source that holding the wall until a bed becomes available is a violation of federal law that the FBI will investigate?



My source would be the appropriate federal statutes. Since most of the facilities that accept incoming adult mental health cases are government run (most usually a county hospital) they become subject to not only the patient dumping statutes, but the statutes under 28 U.S.C. 1983, 18 U.S.C. 241, and 18 U.S.C. 242. The 1983 statute provides a civil cause of action against a government-affiliated employee, and the later statutes involve criminal offenses involving constitutional civil rights which government-run agencies are always subject to. The eighth amendment prohibits any government-run agency, which includes any government-run hospital, from violating the eighth amendment cruel and unusual punishment prohibition, which historically  includes refusal to provide adequate medical care within a reasonable time frame. What constitutes "reasonable" is an issue of law that the court must decide on a case-per-case basis, and is something that a federal district judge must ultimately decide. [Law enforcement are not allowed to determine what constitutes "Reasonable" for these purposes because no statute defines the term "reasonable" as used in the criminal statutes under 18 U.S.C. et seq.) ].  

Hence, the question becomes whether or not it is "reasonable" for a facility to wait one to two hours to examine a psych patient whom, is by DSM-IV defintion, deemed "unstable". (The DSM-IV is considered the holy grail of mental health practice, and is considered to be an absolute authority in the U.S.) Since EMT-P's don't get any psych training whatsoever beyond "stop-gap" measures such as temporary chemical restraint (which has criminal law considerations of it's own to consider and is considered highly problematic unless one can articulate absolute need at the exact moment of time.), We are largely in over our heads in being able to prevent suicide. 

This is because a lot of patients whom need chemical restraint to avoid suicide aren't "combative" in the sense it applies to the EMS world- in that they aren't combative against you, but are rather combative against themselves. Therefore, most patients that actually need chemical restraint don't fall within our classic protocol on the subject. We couple that with the fact that, because we're not trained specifically to articulate mental health state in the language that is inherent to "psych" treatment, MC will be reluctant at best to authorize chemical restraint until things have gotten to the point to where in reality it should have been done way before then. Hence, it becomes that the receiving facility is best equipped to handle the definitive emergency procedure as applies to this type of case, where it is beyond the bare basics, and beyond what the EMT-P is prepared to objectively recognize beyond that of the average citizen. (in that anyone can request a mental health hold for an individual.) This is why psych nurses get training beyond that of an R.N. as applies to the mental health field specifically.

The thing is that "stable" has two totally different definitions depending whether we're talking the physical or mental sense- however, the court will follow the "mental" sense in cases of a suicidal patient, which is beyond our scope of training. Hence it becomes the receiving facility is refusing to deal with a clear emergency in much the same way as if  we were to wait 3 minutes before initiating CPR in a cardiac arrest. Regardless of "bed space" they have the duty to stabilize the patient within reasonable capability. Waiting an hour to do something without referring the patient to a facility that is equipped to handle the situation more expediently  is medically inappropriate and incurs legal liability under the "Reasonableness" doctrine, because a "Reasonable person" in the eyes of the law is a person without advanced training, but a person whom has "common sense". 

The potential net result is that the paramedic incurs liability for acting beyond scope of training in accessing the real potential for harm (since we have no formal mental health training) , and the receiving facility incurs liability because their actions were unreasonable in the eyes of the law.


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## DesertMedic66 (Aug 7, 2017)

So the psych hold that I have written by PD that states the patient “is a danger to themselves” because they want to hang themselves means this patient is unstable and needs a bed ASAP? I think you and everyone else have different views on what stable vs unstable is...


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## MonkeyArrow (Aug 8, 2017)

bakertaylor28 said:


> My source would be the appropriate federal statutes. Since most of the facilities that accept incoming adult mental health cases are government run (most usually a county hospital) they become subject to not only the patient dumping statutes, but the statutes under 28 U.S.C. 1983, 18 U.S.C. 241, and 18 U.S.C. 242. The 1983 statute provides a civil cause of action against a government-affiliated employee, and the later statutes involve criminal offenses involving constitutional civil rights which government-run agencies are always subject to. The eighth amendment prohibits any government-run agency, which includes any government-run hospital, from violating the eighth amendment cruel and unusual punishment prohibition, which historically  includes refusal to provide adequate medical care within a reasonable time frame. What constitutes "reasonable" is an issue of law that the court must decide on a case-per-case basis, and is something that a federal district judge must ultimately decide. [Law enforcement are not allowed to determine what constitutes "Reasonable" for these purposes because no statute defines the term "reasonable" as used in the criminal statutes under 18 U.S.C. et seq.) ].
> 
> Hence, the question becomes whether or not it is "reasonable" for a facility to wait one to two hours to examine a psych patient whom, is by DSM-IV defintion, deemed "unstable". (The DSM-IV is considered the holy grail of mental health practice, and is considered to be an absolute authority in the U.S.) Since EMT-P's don't get any psych training whatsoever beyond "stop-gap" measures such as temporary chemical restraint (which has criminal law considerations of it's own to consider and is considered highly problematic unless one can articulate absolute need at the exact moment of time.), We are largely in over our heads in being able to prevent suicide.
> 
> ...


Ah, now I remember. This guy is the fake lawyer.

You are conflating government funded with government run, first of all. The eight amendment does not apply because no punishment is being carried out by the government. Seeking treatment for psychiatric care is not a punishment issued through the legal system.

You've seemed to lay out a very long explanation of reasonable, which is what the common person would find. Again, hospitals don't make EMS crews wait for fun. The EMS crew is waiting for a bed to clear. No reasonable person would find that a facility at max capacity can somehow abbreviate the wait time for a bed. By doing what, kicking another patient out to make room for the EMS patient?

A psych patient is nothing like a patient in cardiac arrest. One is in immediate and imminent risk of loss of life, the other is not. You even say "within reasonable capability". This means that if no beds are available, you're going to have to wait if you're stable. A non-combative psych patient is stable. By your definition, every abdominal pain or leg pain, which can have a risk of rupturing AAA or DVT turned into PE causing arrest, need to be treated immediately, making every single hospital in the country in violation of federal law since they have people wait in the waiting room.

I really hope you're better at EMS than you are at law.


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## DrParasite (Aug 8, 2017)

You know, @bakertaylor28 actually provided a very well written and properly thought out response...  He even cited the appropriate legal statutes... I would have added that once you arrive in the ER, your patient becomes the hospitals responsibility (per EMTALA), and by holding the wall for an extended period of time, you are providing free labor to the hospital.  

He's still acting like a jackass to the hospital staff, and I wouldn't want to work in the same system as him, but he cited case law and everything.  I'm still waiting for him to call the FBI on the hospitals......

BTW, this is a hospital staffing and bed management issue.  EMS cannot fix the issue, and should not be used as free labor.  EMS should be in the field answering calls, not holding the wall because the hospital doesn't have enough staff or beds to handle the routine influx.  In many other states, if you have a 30 minute wait time, than the hospital needs to go on divert, and all patients should be redirected elsewhere, because the hospital obviously can't handle the workload they currently have.

Why this type of madness is permitted to occur in California is beyond me.


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## gonefishing (Aug 8, 2017)

DrParasite said:


> You know, @bakertaylor28 actually provided a very well written and properly thought out response...  He even cited the appropriate legal statutes... I would have added that once you arrive in the ER, your patient becomes the hospitals responsibility (per EMTALA), and by holding the wall for an extended period of time, you are providing free labor to the hospital.
> 
> He's still acting like a jackass to the hospital staff, and I wouldn't want to work in the same system as him, but he cited case law and everything.  I'm still waiting for him to call the FBI on the hospitals......
> 
> ...


Because up is down and left is right in California.

Sent from my SM-G920P using Tapatalk


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## DesertMedic66 (Aug 8, 2017)

It’s very hard for a hospital to go on divert when pretty much all hospitals in SoCal have crews holding the wall. There are times where I would end up having to drive several hours away to find a hospital without crews holding the wall.


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## DrParasite (Aug 8, 2017)

MonkeyArrow said:


> Again, hospitals don't make EMS crews wait for fun. The EMS crew is waiting for a bed to clear. No reasonable person would find that a facility at max capacity can somehow abbreviate the wait time for a bed. By doing what, kicking another patient out to make room for the EMS patient?


Simple solution: get more beds.  at one former level 1 trauma center, they used to have beds in every room (and by room, i mean area divided by a curtain).  if it got busy, they doubled up.  if all the rooms were doubled up, they put beds in the hall ways.  this ER had 3 trauma rooms; trauma 1, trauma 2, and shock trauma.  Trauma 1 and 2 could hold 4 patients each.  Shock trauma was reserved for an unexpected trauma.   and if they get hit with multiple traumas, than patient's get relocated (often into the hall ways or they open up other areas for overflow).  It's not rocket science, and I can't understand why so many California hospitals can't handle the routine call volume.

Yes, you need to hire more staff, yes, it's a budget issue, but if the patient volume is there, I bet a good attorney could make a good negligence case that the hospital was failing to do their job by staffing appropriately, tying up 911 resources that are unavailable to respond to their primary coverage areas for extended periods of time because despite the obvious need, hospital management will not allocate funding appropriately.  Would he win?  IDK, but I think he could make a strong case for it.


DesertMedic66 said:


> It’s very hard for a hospital to go on divert when pretty much all hospitals in SoCal have crews holding the wall. There are times where I would end up having to drive several hours away to find a hospital without crews holding the wall.


Sounds like a systematic issue. 

Maybe they should take some lessons from their east coast counterparts, who don't have these issues yet have more population to deal with over a smaller area?


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## bakertaylor28 (Aug 8, 2017)

MonkeyArrow said:


> Ah, now I remember. This guy is the fake lawyer.
> 
> You are conflating government funded with government run, first of all. The eight amendment does not apply because no punishment is being carried out by the government. Seeking treatment for psychiatric care is not a punishment issued through the legal system.
> 
> ...


Government funded and government- run are the same thing for purposes of 1983 complaints and civil rights law. Plus most "County" hospitals are owened in part by the government. eighth amendment law is also not necessarily restricted to criminal punishment- it has been expanded over the years via court decisions to include civil torts involving any case in which a person is placed on involuntary hold via a court order for a non-criminal reason, such as contempt of court and psych holds.  The legal test is whether or not the patient is subject to conditions which are tantamount to "incarceration" of any kind.  If a facility doesn't have beds available, then the reasonable and prudent thing to do is to refer a patient to a facility that has a bed available within a reasonable amount of time, provided the patient is stable. (which again, under our circumstances, the law doesn't consider our patient "stable" by definition of mental health practice.)  Your confusing the mental health definition of "stable" with the ordinary meaning of the terminology, and the two are not the same in the eyes of the law. For purposes of law, a suicidal patient is just as "unstable" as a patient in cardiac arrest- as a suicidal patient can be just as much on death's doorstep without relatively immediate intervention- the difference is that there's quite a bit more time before the crap hits the fan.  The question really is "how much" - and the reasonable and prudent person doesn't gamble. Hence waiting 20-30 minutes is reasonable. Waiting 1 to 2 hours is not.


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## DesertMedic66 (Aug 8, 2017)

Our hospitals have tried putting beds in hallways but they can only put soo many before it becomes a fire hazard (our hospitals have actually been cited by the fire marshal for it). 

The hospitals in my area have several issues. These include a shortage of ER nurses, not enough ER beds, not enough ICU beds, not enough tele-beds. They will have patients wait hours in the ED before an ICU bed opens up. There is also a huge issue with pysch patients in my area. All psych patients have to be medically cleared from the ED and then the ED will work on placement for them which can easily take 3 days. It’s hard to do anything when the whole hospital is literally full with patients. 

Are there things that they could change? I’m sure there is. I’m not familiar with how other areas operate and I have no clue about the hospital administrator aspect.


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## bakertaylor28 (Aug 8, 2017)

DesertMedic66 said:


> Our hospitals have tried putting beds in hallways but they can only put soo many before it becomes a fire hazard (our hospitals have actually been cited by the fire marshal for it).
> 
> The hospitals in my area have several issues. These include a shortage of ER nurses, not enough ER beds, not enough ICU beds, not enough tele-beds. They will have patients wait hours in the ED before an ICU bed opens up. There is also a huge issue with pysch patients in my area. All psych patients have to be medically cleared from the ED and then the ED will work on placement for them which can easily take 3 days. It’s hard to do anything when the whole hospital is literally full with patients.
> 
> Are there things that they could change? I’m sure there is. I’m not familiar with how other areas operate and I have no clue about the hospital administrator aspect.



This is where they need to be transferring stable patients to other facilities with capability to treat. It's also an area where they need to discharge those ER cases that should be "urgent care" cases- Way too many people clog up the ER with non-life threatening conditions because they can't afford typical treatment. The solution to this is to classify "urgent care" centers as emergency medicine and subject them to the same financial rules. (i.e. that you can't deny a patient for financial reasons.) This, in turn, would rely on proper management of government funds, and congress taking a pay cut. Fat chance in all reality, but that's what needs to happen.


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## Jim37F (Aug 8, 2017)

Back to the original patient, she was a voluntary admit. She voluntarily called 911 herself and requested to be transported due to feeling suicidal, while def stressed, was otherwise completely calm and cooperative and basically just needed a ride....can see why the probably overworked Sheriff's Deputies didn't see a need to add any more paperwork to their dockets...or why the medics felt any need to ALS a calm, stable patient. Here Psych is BLS all day every day until chemical restraints are required, even if physical restraints are required but not chemical restraints, it's still a BLS patient. 
(And never mind that up until about hour 3? When the original patient started getting anxious and wanting to get off the gurney did she do anything other than sit on the gurney, yes verbally expressing her unhappiness with the wait... but displayed absolutely zero indications of needing restraints at all....so if you're already upset over a BLS crew waiting that long, how does replacing them with an ALS crew help anything?)



DrParasite said:


> Why this type of madness is permitted to occur in California is beyond me.


If every hospital with a 30+min wait went on diversion, that'd be almost literally every single hospital in my old service area. And that's about a 12 mile radius with almost a dozen hospitals in it, including 2 level 1s, a level 2, a burn center, 2 or 3 Kaisers, multiple STEMI and Stroke receiving centers, is be driving through an hour or more of LAs best traffic to reach one that let that criteria, and so would everyone else, pretty soon I'd be picking up a patient in Compton and driving them to Bakersfield if that was the case!

Yes the solution is more beds and the staff to attend to the patients in them....but that requires funding....and remember many So Cal hospitals in recent years have closed down their ERs due to lack of funding (and no hospital is going to call a stream of non emergency ambulances just to transport out stable patients who've been waiting a while....no insurance is going to pay for the transport of a stable patient simply because they're waiting a while


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## DrParasite (Aug 8, 2017)

Jim37F said:


> When the original patient started getting anxious and wanting to get off the gurney did she do anything other than sit on the gurney, yes verbally expressing her unhappiness with the wait... but displayed absolutely zero indications of needing restraints at all....so if you're already upset over a BLS crew waiting that long, how does replacing them with an ALS crew help anything?)


sounds like a good reason to take them off your stretcher, put them in a chair, an have hospital personnel babysit the patient instead of keeping them on the cot, tying up an ambulance crew.  And the justification for keeping you guys?  did the hospital not have a spare chair for the patient to sit in?


Jim37F said:


> If every hospital with a 30+min wait went on diversion, that'd be almost literally every single hospital in my old service area. And that's about a 12 mile radius with almost a dozen hospitals in it, including 2 level 1s, a level 2, a burn center, 2 or 3 Kaisers, multiple STEMI and Stroke receiving centers, is be driving through an hour or more of LAs best traffic to reach one that let that criteria, and so would everyone else, pretty soon I'd be picking up a patient in Compton and driving them to Bakersfield if that was the case!


 blah, blah, blah... not every patient in your level 1 or 2 are traumas, not ever patient in the STEMI or stroke are stemi or stroke patients.  all those designations tell me is you have a variety of options for where you can take the critically sick patients, much more than my "we only have one level 1 trauma center in the county" or "we only have 1 burn center in the state."

You know, we have this thing called triage in most of the ERs... if your patient comes in by ambulance, and isn't sick, and can wait, they go sit in the triage area, until they are called.  I think I even had one instance where we had a very stable BLS patient, who couldn't sit in a chair, so we put them on a hospital bed, and wheeled the bed to the triage area until they were called


Jim37F said:


> Yes the solution is more beds and the staff to attend to the patients in them....but that requires funding....and remember many So Cal hospitals in recent years have closed down their ERs due to lack of funding (and no hospital is going to call a stream of non emergency ambulances just to transport out stable patients who've been waiting a while....no insurance is going to pay for the transport of a stable patient simply because they're waiting a while


more excuses.... So Cal is not unique in this regard, there are plenty of areas that function better on the east coast, with larger populations, more poverty, and smaller tax bases.  You can look up the numbers yourself in my other posts.

The real problem is the ambulance companies accept this and are willing to work as unpaid supplemental hospital staff.  As long as they are willing to do it, there is 0 reason the hospitals should be turning down free labor.

I think we have beat this horse to death..... We aren't going to fix the hospital's bed management issue, nor their staffing issue (and the hospital's don't seem to be in any rush to fix it), and if the people on the west coast are ok with holding a wall for several hours, why should anyone else care?


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## Medic27 (Aug 10, 2017)

My understand is if they are alert and oriented times 3, not making threats or using violence towards others you have to let them go. Personally, I would contact our medical director for advice.


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## wtferick (Aug 13, 2017)

I don't trust PD all to often.. they handcuffed our patient to the gurney on scene.. never met us at the ER.


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## Jim37F (Aug 13, 2017)

wtferick said:


> I don't trust PD all to often.. they handcuffed our patient to the gurney on scene.. never met us at the ER.


One time we had a call where LA Co Sheriff's handcuffed our patient to the gurney (it must've been a fairly big call, I think SWAT got called out? I don't remember, but there were like 50 LEOs there at least.....) and we were going to transport BLS, so the fire crews (NOT LACoFD, but one of the smaller departments McCormick just started transporting for back in January....) were going to clear and go back to station (this was like 11 at night or thereabouts)....but for whatever reason they wanted to wait for us to actually start transporting to leave themselves. Not sure why, but they did. AND they were impatient about it for......reasons? They (Fire) wanted us to hurry up and start transporting, didn't understand why I (I was the driver that shift) was dead set on waiting for someone from Sherrif's to be clearly ready to come with us.....even after I explained how if I drove off then and there I'd be at the hospital with a handcuffed patient and no one to unlock the handcuffs......Naw they'll meet you there......sure they will.....

Well the Deputy who had actually cuffed the guy had walked off, talking to his Sergeant or whatever, but us and fire didn't know where exactly he was, and none of the Deputies seemed to be in a hurry to jump in the back of our rig or even just plain follow in a squad car. If I had let the fire guys talk me into leaving, and if anything would have happened to the patient enroute (you know, the whole reason why they're making us transport in the ambulance vs in one of the Sherrif's squad cars).......(not to mention that we wouldn't have been able to actually transfer the patient off the gurney at the hospital! So yeah, even though we had the patient loaded up, ready to go, even though Fire seemed to have decided they can't clear till I was driving off and were antsy to do just that and kept telling me to do so, I pissed the Capt off by flat out refusing to go anywhere until a Deputy with the handcuff key was firmly seated in the back of the ambulance.


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## wtferick (Aug 13, 2017)

Jim37F said:


> One time we had a call where LA Co Sheriff's handcuffed our patient to the gurney (it must've been a fairly big call, I think SWAT got called out? I don't remember, but there were like 50 LEOs there at least.....) and we were going to transport BLS, so the fire crews (NOT LACoFD, but one of the smaller departments McCormick just started transporting for back in January....) were going to clear and go back to station (this was like 11 at night or thereabouts)....but for whatever reason they wanted to wait for us to actually start transporting to leave themselves. Not sure why, but they did. AND they were impatient about it for......reasons? They (Fire) wanted us to hurry up and start transporting, didn't understand why I (I was the driver that shift) was dead set on waiting for someone from Sherrif's to be clearly ready to come with us.....even after I explained how if I drove off then and there I'd be at the hospital with a handcuffed patient and no one to unlock the handcuffs......Naw they'll meet you there......sure they will.....
> 
> Well the Deputy who had actually cuffed the guy had walked off, talking to his Sergeant or whatever, but us and fire didn't know where exactly he was, and none of the Deputies seemed to be in a hurry to jump in the back of our rig or even just plain follow in a squad car. If I had let the fire guys talk me into leaving, and if anything would have happened to the patient enroute (you know, the whole reason why they're making us transport in the ambulance vs in one of the Sherrif's squad cars).......(not to mention that we wouldn't have been able to actually transfer the patient off the gurney at the hospital! So yeah, even though we had the patient loaded up, ready to go, even though Fire seemed to have decided they can't clear till I was driving off and were antsy to do just that and kept telling me to do so, I pissed the Capt off by flat out refusing to go anywhere until a Deputy with the handcuff key was firmly seated in the back of the ambulance.


Luckily our crews started having PD take them in stead of us. They would aways come in clutch in the early mornings.


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## Jim37F (Aug 13, 2017)

Meanwhile, I've had LACo Fire pull patients out of the back seat of squad cars to put them in the ambulance, even though the Deputy was saying that it's alright, they'd take them in themselves, it's just a clear to book, and they would still have to follow to the hospital and wait there until the pt was cleared so they can go to jail anyway, and LACoFD saying "No, you called us and we had to check them out, that makes them our patient, now we HAVE to transport by ambulance because there's a one in a million chance it's a stroke or something instead....but we're clearing and going back to station, McCormick you're transporting to the psych hospital code 2 BLS, see ya in a few hours" (at least up until the ellipses, that was almost verbatim.....)

(One time a Deputy was leading a guy out to us in Compton, we were on scene first, Deputy was about to sit the guy on the gurney when CFD walks up and shouts to not do that if it's just a clear to book.....the Compton guys said that as soon as they sit on the gurney they become a patient that HAS to be transported via ambulance to the hospital but if they didn't sit down the Deputy could take them to the hospital or straight to jail or whatever they wanted to do instead.....)


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## Akulahawk (Aug 13, 2017)

bakertaylor28 said:


> Government funded and government- run are the same thing for purposes of 1983 complaints and civil rights law. Plus most "County" hospitals are owened in part by the government. eighth amendment law is also not necessarily restricted to criminal punishment- it has been expanded over the years via court decisions to include civil torts involving any case in which a person is placed on involuntary hold via a court order for a non-criminal reason, such as contempt of court and psych holds.  The legal test is whether or not the patient is subject to conditions which are tantamount to "incarceration" of any kind.  *If a facility doesn't have beds available, then the reasonable and prudent thing to do is to refer a patient to a facility that has a bed available within a reasonable amount of time, provided the patient is stable. (which again, under our circumstances, the law doesn't consider our patient "stable" by definition of mental health practice.)*  Your confusing the mental health definition of "stable" with the ordinary meaning of the terminology, and the two are not the same in the eyes of the law. For purposes of law, a suicidal patient is just as "unstable" as a patient in cardiac arrest- as a suicidal patient can be just as much on death's doorstep without relatively immediate intervention- the difference is that there's quite a bit more time before the crap hits the fan.  The question really is "how much" - and the reasonable and prudent person doesn't gamble. Hence waiting 20-30 minutes is reasonable. Waiting 1 to 2 hours is not.


What you're now suggesting is that a hospital violate EMTALA by referring a patient to another facility without conducting a medical screening exam, performing any and all necessary testing to determine the patient is actually medically stable for said transfer, and without the receiving facility's acceptance of said patient. A suicidal patient that's in restraints for their own safety (let alone mine) while waiting for an appropriate bed, appropriate MSE and testing, and appropriate referral, while "unstable" isn't in an unsafe situation while waiting. No hospital that I'm aware of is going to violate EMTALA because they don't want to have a patient hold a wall for more than an hour or two. Sure, while the suicidal patient needs relatively immediate intervention, the time scale for "immediate" can be quite different from other ESI 1 patients because the patient is not in a physically unsafe situation.


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## DrParasite (Aug 13, 2017)

wtferick said:


> I don't trust PD all to often.. they handcuffed our patient to the gurney on scene.. never met us at the ER.


If PD has our patient handcuffed to the gurney, they WILL be transporting in the truck with us.  It's not even up for debate, my truck isn't leaving the scene without LEO in the back with us.  If needed, I'll have my supervisor speak to their supervisor, and if my supervisor can't convince their supervisor to send a cop with us, than he can take the ride in the back with the patient to the hospital and I will take his car back to base and we can discuss it with administration.


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## DrParasite (Aug 13, 2017)

Jim37F said:


> Meanwhile, I've had LACo Fire pull patients out of the back seat of squad cars to put them in the ambulance, even though the Deputy was saying that it's alright, they'd take them in themselves, it's just a clear to book, and they would still have to follow to the hospital and wait there until the pt was cleared so they can go to jail anyway, and LACoFD saying "No, you called us and we had to check them out, that makes them our patient, now we HAVE to transport by ambulance because there's a one in a million chance it's a stroke or something instead....but we're clearing and going back to station, McCormick you're transporting to the psych hospital code 2 BLS, see ya in a few hours" (at least up until the ellipses, that was almost verbatim.....)


sounds like another reason to not work in the LA area.....





Jim37F said:


> (One time a Deputy was leading a guy out to us in Compton, we were on scene first, Deputy was about to sit the guy on the gurney when CFD walks up and shouts to not do that if it's just a clear to book.....the Compton guys said that as soon as they sit on the gurney they become a patient that HAS to be transported via ambulance to the hospital but if they didn't sit down the Deputy could take them to the hospital or straight to jail or whatever they wanted to do instead.....)


why makes the patient NEED to go to the hospital once he sits on the stretcher?  Is that a local policy thing?  medical director's call?  a Cali regulation?  

I would argue that why even send an ambulance a?t all?  just have the FD do it with no ambulance or stretcher present, so there is no risk of them getting on the stretcher.

Even better, what makes the FD qualified to clear a patient for booking?  I mean, don't your jails have medical staff who handle stuff like this?


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## Jim37F (Aug 14, 2017)

Yeah....I've asked those exact same questions myself.....never really got much of a better answer than "Oh that's not PDs job" or "That's just the way it is....that's your job, if you don't like,  the door is over there" -_-

(Though we were all fairly certain some of the other departments that actually had to transport and deal with wall holding and being out of service for such patients were more than happy to let LE transport in those cases.....)

If I hadn't won the proverbial lottery when I did, I would have already been looking at exit routes (I already knew that if I hadn't passed my interview back in Feb I'd have been applying to medic school for this fall at the least.....would still have gone thru the proverbial revolving door even if my exit wasn't to come up till next spring or whatever I was already looking towards it....)


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