Scene times

[DrParasite]

on scene times for serious patients are typically under 30 minutes. for stable, ambulatory patients, on scene time is typically under 10 minutes.

for serious patients where the patient needs more help than I can provide, on scene time is typically under 10 minutes.

I also try to transport EVERYONE. If they call for an ambulance, I will do what I can on scene, and then transport them to the ER, even if I think they don't need it. No need convincing a person to RMA, only to have them call back 20 minutes later. the exception being cardiac arrests, if they can be pronounced on scene, they stay there.

Two of the first questions I ask all my patients are "what's the problem today" and "which hospital are we going to. one EMT bring in the clipboard/toughbook and stairchair (always bring a carrying device), while the other brings oxygen and jump kit.

if I end up on a 3 person ALS or CCT unit (which i really don't like being on), the EMT grabs the stairchair, the medic grabs the drug bag and airway bag, and the nurse grabs the monitor. if we go into a big building, cot goes in instead of stairchair.

either way, as one person does a rapid assessment (looking for life threats), the other either starts documentation or starts preparing for transport. The follow up assessment can be done enroute to the hospital, as can many interventions. If the person is sick, apply oxygen (yes yes, I know), move to stairchair and carry to truck and start going to the hospital, all in under 10 minutes. If the person is not sick, no need to waste time on scene, assist to ambulance and continue your assessment while enroute to the hospital.

nothing infuriates me more as a resource management specialist than having a crew spending 30 minutes to an hour or more on an ambulatory non-critical patient, especially when there are other more critical calls holding and no mutual aid available (another topic altogether, but we won't digress too far).

 

[Handsome Robb]

I also try to transport EVERYONE. If they call for an ambulance, I will do what I can on scene, and then transport them to the ER, even if I think they don't need it. No need convincing a person to RMA, only to have them call back 20 minutes later. the exception being cardiac arrests, if they can be pronounced on scene, they stay there.

May I ask why?

Not trying to start an argument but why add unnecessary load on the already taxed healthcare system if you think/know someone doesn't need a hospital?

You aren't the only person I've heard this thought process from but I still don't understand it. If I can "fix" someone on scene and leave them there why wouldn't I?

 

[the_negro_puppy]

I do not agree with the notion that all patients should be transported. Grante d our system and laws are different to the US., but transporting everyone "just in case" or to prevent "more calls" is lazy, shows a lack of confidence in your assessment skills and adds unnecessary strain to the emergency healthcare system.

DrParasite I must say you contradict yourself. On one hand you criticise crews for spending long periods of time with non-urgent ambulatory patients as they may be needed for more urgent matters, yet you personally advocate transporting everyone who calls to the ED. What happens to little Sally who has drowned in the pool when the only Ambulance within 20 minutes L&S drive is transporting a young, healthy male adult with diarrhoea for the past 4 hours?

I think part of EMS becoming a profession is having some autonomy. If you transport every caller to hospital and have to call physicians for permission to give drugs or treat then your job as a clinician is marginalised. is your role is blurred with that of a taxi driver.

 

[mycrofft]

Dr Parasite may be pointing out the paradox in American EMS. The tech is at the mercy of at least two or three levels of scrutiny who can't all agree on one set of standards. Damned if you do, damned if you don't, and the best way out of that is pass the issue upstream.

The USA model also has at root that field EMS is an intake mode for hospitals, a way to get patients to them alive. Otherwise, the techs are practicing medicine, and there you go again, another layer of oversight, defensive criticism, and etc.

 

[DrParasite]

Not trying to start an argument but why add unnecessary load on the already taxed healthcare system if you think/know someone doesn't need a hospital?

because the person wants to go to the hospital. If I talk the person into refusing to be transported, there is a high probability that they are just going to call an hour later for an ambulance. or i can get an RMA, and they they can call my boss and tell them they wanted to go to the hospital, but I convinced them not to. And like the person who called 911 because their hairdye was burning their scalp..... yes it was a BS call, yes, the person would be a lot better if they just washed the dye out, but the person wanted to go to the hospital.....

If I can "fix" someone on scene and leave them there why wouldn't I?

what are you "fixing"? outside of waking up a diabetic (which I agree, raise the sugar, have them eat a sandwich, and RMA), how much permanent fixing do we really do?

I do not agree with the notion that all patients should be transported. Grante d our system and laws are different to the US., but transporting everyone "just in case" or to prevent "more calls" is lazy, shows a lack of confidence in your assessment skills and adds unnecessary strain to the emergency healthcare system

DrParasite I must say you contradict yourself. On one hand you criticise crews for spending long periods of time with non-urgent ambulatory patients as they may be needed for more urgent matters, yet you personally advocate transporting everyone who calls to the ED. What happens to little Sally who has drowned in the pool when the only Ambulance within 20 minutes L&S drive is transporting a young, healthy male adult with diarrhoea for the past 4 hours?

As many have told me both on here and in real life, you can't let how you treat one patient affect a call you may or may not get. For example, if your young adult male is massively dehydrated, and needs IV fluids or else he will die, would you say he shouldn't be transported so you can handle the pediatric drowning that might come in?

Once you make patient contact, you can't severe it unless the patient chooses too, so you should not waste time on scene, just start going to the hospital so you can be back available to save Sally from drowning.

is your role is blurred with that of a taxi driver.

I've transported so much BS , where the patient just need a ride to the ER (or more likely, a ride to their PMD or even a day or two to rest and let the body heal on it's own).

Dr Parasite may be pointing out the paradox in American EMS. The tech is at the mercy of at least two or three levels of scrutiny who can't all agree on one set of standards. Damned if you do, damned if you don't, and the best way out of that is pass the issue upstream.

The USA model also has at root that field EMS is an intake mode for hospitals, a way to get patients to them alive. Otherwise, the techs are practicing medicine, and there you go again, another layer of oversight, defensive criticism, and etc.

unfortunately, mycrofft is partially right. EMS (and the ER in general) are often the gateway to the healthcare system. people call 911 to go to the hospital, and the cycle continues.

I would LOVE to be able to say "sir/ma'am, you don't need to go to the ER." I would LOVE to be able to say "despite you calling for an ambulance to take you to the ER, you don't need an ambulance. you might need a taxi.... or an appointment with your PMD, but you don't need my services." And I would LOVE to say "drunk person, go sleep it off, you got yourself drunk, now deal with the wicked hangover." And I would LOVE to say "we are refusing to take you to the ER, and if you call back, the next crew is just going to say the same thing."

But that's not the world we live in, and most systems say if you call for an ambulance, an ambulance will show up (sooner or later) and take you to the ER.

 

[WuLabsWuTecH]

Not getting into that mess just above me, but I will agree with parasite here on at least one thing:

You take care of the emergency you have now, and not the ones that you might have later. In a rural system where a run from start to finish can take up to 2 hours on average (20 minute response on average + 25 minute transport times on average) and if we're all the way out to the end of our run district on a trauma can take up to 4 hours (42 minutes to the end or our run district, + 1 hour to the trauma center away from station, + 1 hr and 30 minutes back to station) we would be the perfect candidate for resource management. But we don't do it. We send everything we might need now, and if we can't take care of it, we'll let mutual aid cover for us. There was talk when we got partial staffing for the second truck (vs. respond from home) that we'd send the Squad on BLS runs, and the Medic on ALS based on the dispatch but the Chief shot that down.

"We are a Medic Service, and when possible, we will provide a Medic Service. The people pay for a medic service and even if it is BLS, I intend on providing them with a Paramedic on scene whenever possible."

That was the end of that discussion.

 

[Handsome Robb]

How about the breather I sat on scene with for a little bit and AMA'd. Documented hx of asthma, great historian, her inhaler wasn't working, she took her oral steroids as we were arriving, I sat around, gave her a few treatments, talked to her and her husband about options, wheezing cleared up, WOB decreased, SpO2 increased as FiO2 was decreased, HR and BP dropped to normal for the pt. What else would the hospital have done for that patient? What? Please tell me? Your example with the hair dye, did you tell them to wash their damn hair? Diabetics obviously are easy if they are hypoglycemic. Minor cuts and scrapes? Again easy - clean, bandage, leave some supplies to clean and bandage along with directions for wound care - fixed.

If you're too lazy to tell someone they don't need a hospital and help guide them with options available to them that's your problem. "Because someone might call back" is a crappy reason.

"Ma'am/Sir, I am more than happy to take you to the hospital, with that said I will tell you now that you will be going to the waiting room. Just because you go in by ambulance does not guarantee you get a bed. With everything that I'm seeing right now I see no reason for you to pay a huge ambulance bill when this could easily be handled by your primary physician or an urgent care. I have to tell you my spiel though: My assessment is not secondary to a physician, there could be something underlying that I can't see or test for in the field that may lead to further complications in the future which may include but are not limited to permanent disability, paralysis, coma and/or death. Now with that said I see absolutely nothing that leads me to believe that something of that nature is going on right now otherwise I wouldn't be giving you this whole spiel. Like I said before I am more than happy to take you to the hospital but we are at the point that we need to make a decision, go or stay. With what I have just told you would you still like to go to the hospital with me today?"

Don't give me the "I work in a busy system" rundown. I work in a busy system as well. Maybe not as busy as yours but we end up with calls holding every now and again. We end up level 0 with no ambulances available in the city. I know how it is.

What you just said to me basically screams lazy. Sure it's easier to write a transport chart than an AMA chart for you but is it easier for the rest of the healthcare system or for that patient who's insurance probably isn't going to cover the transport since it wasn't medically necessary? Now they are stuck with a $1000+ bill that they wont/can't pay and the rest of the system is stuck with a person who does not need to be taking up a hospital room. All because "they might call back again" and you didn't want to take the time to write an AMA chart. How is sticking a patient with an unnecessary ambulance bill being a good patient advocate? It's not.

 

[DrParasite]

How about the breather I sat on scene with for a little bit and AMA'd. Documented hx of asthma, great historian, her inhaler wasn't working, she took her oral steroids as we were arriving, I sat around, gave her a few treatments, talked to her and her husband about options, wheezing cleared up, WOB decreased, SpO2 increased as FiO2 was decreased, HR and BP dropped to normal for the pt. What else would the hospital have done for that patient? What? Please tell me?

great example. Let me ask another question: was her inhaler not functioning properly, or was the medication in it (typically albuterol) not relieving her wheezing? If it's the former, than your example is the rarity, not the norm. if it's the latter, than the albuterol isn't working, and I'm thinking solumedrol and maybe epi since the first line med isn't working. Or even better, now that you have fixed her with your meds, when she has another attack, her inhaler still won't help, and guess what the next call will be? you are going back to help her.

Your example with the hair dye, did you tell them to wash their damn hair? Diabetics obviously are easy if they are hypoglycemic. Minor cuts and scrapes? Again easy - clean, bandage, leave some supplies to clean and bandage along with directions for wound care - fixed.

sounds great, but if they want to go to the hospital, are you going to tell them no? plus if they have minor cuts and scrapes, why on earth did they call an ambulance?

If you're too lazy to tell someone they don't need a hospital and help guide them with options available to them that's your problem. "Because someone might call back" is a crappy reason.

it has nothing to do with being lazy; most patients in my system don't need a hospital. but they still want to go. what will your bosses say if you start telling people you won't transport them, even if they want to go to the hospital?

"Ma'am/Sir, I am more than happy to take you to the hospital, with that said I will tell you now that you will be going to the waiting room. Just because you go in by ambulance does not guarantee you get a bed. With everything that I'm seeing right now I see no reason for you to pay a huge ambulance bill when this could easily be handled by your primary physician or an urgent care. I have to tell you my spiel though: My assessment is not secondary to a physician, there could be something underlying that I can't see or test for in the field that may lead to further complications in the future which may include but are not limited to permanent disability, paralysis, coma and/or death. Now with that said I see absolutely nothing that leads me to believe that something of that nature is going on right now otherwise I wouldn't be giving you this whole spiel. Like I said before I am more than happy to take you to the hospital but we are at the point that we need to make a decision, go or stay. With what I have just told you would you still like to go to the hospital with me today?"

and after you spend 20 minutes convincing them they don't need an ambulance, instead of 5 minutes transporting them to the ER, which has been a better use of your time? But your right, I could tell her exactly what you just said. and if she still wants to go.....

Don't give me the "I work in a busy system" rundown. I work in a busy system as well. Maybe not as busy as yours but we end up with calls holding every now and again. We end up level 0 with no ambulances available in the city. I know how it is.

ahh level 0.... when you are are level -8 (that's 8 jobs holding with 0 units available) for 6 straight hours, then come talk to me. And yes, please don't bring up "well that's what mutual aid is for" management has decided we are not to use it for BLS calls, not my call, people who make more money than I made that decision. And yes, we should have more units, but don't have the funding for them (again, above my paygrade).

What you just said to me basically screams lazy. Sure it's easier to write a transport chart than an AMA chart for you but is it easier for the rest of the healthcare system or for that patient who's insurance probably isn't going to cover the transport since it wasn't medically necessary? Now they are stuck with a $1000+ bill that they wont/can't pay and the rest of the system is stuck with a person who does not need to be taking up a hospital room. All because "they might call back again" and you didn't want to take the time to write an AMA chart. How is sticking a patient with an unnecessary ambulance bill being a good patient advocate? It's not.

lazy, what the bosses want, what is less potential litigious exposure for the provider, making the best use of my time, call it whatever you want. Doesn't mean your right, just what you are calling it.

If they call for an ambulance, requesting transport to the hospital, even if its for a reason that I don't think warrants it, than I will assist them to the truck, and transport them to the ER, as they are requesting. If you want to talk them into RMAing, that's on you.

 

[WuLabsWuTecH]

OK... I'm convinced to jump into the fray...

[/quote]

great example. Let me ask another question: was her inhaler not functioning properly, or was the medication in it (typically albuterol) not relieving her wheezing? If it's the former, than your example is the rarity, not the norm. if it's the latter, than the albuterol isn't working, and I'm thinking solumedrol and maybe epi since the first line med isn't working. Or even better, now that you have fixed her with your meds, when she has another attack, her inhaler still won't help, and guess what the next call will be? you are going back to help her. sounds great, but if they want to go to the hospital, are you going to tell them no?

This is a definite possibility. Our policy is that we are not a pharmacy on wheels. If we give you meds, then we transport. The exception is D50/oral glucose for hypoglycemics and sometimes albuterol for asthmatics. The reason for this is that we don't want people calling us because they are too lazy to refill their meds and then when they need it, just call us to come give some to them. But once in awhile, we all make mistakes and if it's not a frequent patient, or it's a transient person (I came to the state park and forgot my albuterol and now I'm on my way home to get it) we might give it at paramedic discretion.

plus if they have minor cuts and scrapes, why on earth did they call an ambulance?

Your guess is as good as mine. But we do see it here in my area. Often these are walk-ins but sometimes they call 911. There was a girl whose mother called us at 8pm when she got home from work claiming that her daughter was cut by a teacher at school. The story was that a sharp pencil the teacher was carelessly using to write something to the student cut her and scratched her. The girl was a very dark skinned african american and it took us about 15 minutes just to identify where the "scratch" was (there was nothing there). We put a band-aid on it and were getting ready to leave when she insisted we transported the child to Children's Hospital, 45 minutes away. We told her we were willing to take her to the county hospital if she really wanted it, but we weren't going to Children's b/c there was no need for a Level I trauma center. Luckily PD convinced mom not to have daughter transported.

In hindsight, after PD came to talk to us at dinner, we decided that she wanted to file suit against the school based on her comments to the LEO.

it has nothing to do with being lazy; most patients in my system don't need a hospital. but they still want to go. what will your bosses say if you start telling people you won't transport them, even if they want to go to the hospital?
and after you spend 20 minutes convincing them they don't need an ambulance, instead of 5 minutes transporting them to the ER, which has been a better use of your time? But your right, I could tell her exactly what you just said. and if she still wants to go.....

It's different depending on where you are. In my suburban department, this is a load and go situation, where we have patient hop up onto the bench seat, strap them in, vitals en route, and report enroute. In a rural area, 15 minutes telling them they probably don't need to go will save you an hour and a half. Yes, treat what you have in front of you and not what might come later, but what you have in front of you doesn't need an ER.

ahh level 0.... when you are are level -8 (that's 8 jobs holding with 0 units available) for 6 straight hours, then come talk to me. And yes, please don't bring up "well that's what mutual aid is for" management has decided we are not to use it for BLS calls, not my call, people who make more money than I made that decision. And yes, we should have more units, but don't have the funding for them (again, above my paygrade).lazy, what the bosses want, what is less potential litigious exposure for the provider, making the best use of my time, call it whatever you want. Doesn't mean your right, just what you are calling it.

Yep, you are right on this one--it's a management issue that they don't want mutual aid called. Not your problem. If your bosses want transport, that's a different issue from if you want to transport all the time. My bosses want all ALS transported if possible, and as mentioned above, anytime we give a drug, they want it transported. BLS calls we can turf at our discretion. If they don't need an ER, then we can tell them that and we don't try to convince them to go. If they insist on going, take them to the county ER.

If they call for an ambulance, requesting transport to the hospital, even if its for a reason that I don't think warrants it, than I will assist them to the truck, and transport them to the ER, as they are requesting. If you want to talk them into RMAing, that's on you.

If they really want to go, I'll take them, but if they are not sure or I can convince them that they don't need an ER, that's also worth a shot. Remember that providing good patient care is a holistic thing. IF they don't need an ER, why subject them to that bill? As medical professionals, it's our job not only to provide them medical service, but also identify to them when certain services are not necessary for them.

 

[mycrofft]

I believe the OP's service is more primary-care-oriented than USA is, they can do different things and they have a different philosophy.

 

[Melclin]

Just as a side note to any mods looking on, I'm happy, as the OP, in how this discussion is evolving. Its different stuff to the original questions, but the questions have been largely answered and the current discussion is natural and interesting. Please don't close it.

If I talk the person into refusing to be transported, there is a high probability that they are just going to call an hour later for an ambulance.

....

.....what are you "fixing"? ?

.....

Once you make patient contact, you can't severe it unless the patient chooses too, so you should not waste time on scene, just start going to the hospital so you can be back available to save Sally from drowning.
I've transported so much BS , where the patient just need a ride to the ER (or more likely, a ride to their PMD or even a day or two to rest and let the body heal on it's own).unfortunately, mycrofft is partially right. EMS (and the ER in general) are often the gateway to the healthcare system. people call 911 to go to the hospital, and the cycle continues.

First paragraph: I think this is where we all tend to get a few wires crossed. As I've often said before (too often some might say ) , some interesting research done here indicated that people call EMS when they lose the ability to cope with a situation that is vaguely medical in nature. Not because they thought they were experiencing a medical emergency and not because they wanted to go to hospital.

The endpoint of our interaction with that person should be to solve their problem both medical and in regards to their ability to cope. Now sometimes it is purely medical, kid falls over at school, break ankle. Coping capacity is not the issue. Most calls aren't like that. There are often numerous psychosocial issues that lead to the person being unable to cope with this vaguely healthcare related problem. So now we basically have three issues:

1: Larger psychosocial issues: Now we often can't fix these in their entirety, although starting a person on that path is a good way of helping the next issue which is their coping capacity. We can, however, often activate agencies involved in this area. Falls referral type services and counselling services are probably the most common type of thing I've been involved with. Making a few phone calls, getting counselling set up, appointments made, OT services organised. Back where I used to work I pointed a few carers of people with mental health problems in the direction of local carer support groups. You're all quite right. We are one of the gateways to the healthcare system, but why on earth does that only have to mean the ED?.

2: Coping capacity in regards to the specific health problem. This is often where care plans come in. I've seen so many chemo pts that hadn't been educated about n&v&d as well as the diet, hydration and antiemetic strategies they should be employing. So many people who failed to take their own meds, or whole have a primary care issue that requires follow up with the PCP/GP. What these people need is education and a plan for there healthcare. Everyday I spend in ambulance, I get more and more into the idea of care plans.

Now when you fix their coping capacity they don't tend to call back in 40 mins. Its not about "convincing" them they don't need an ED and leaving. No wonder they call back. You haven't fixed anything. Educate them. Build a care plan. Build a consensus about the direction they want to take their care and clearly lay it out (on paper preferably) for both of you agree on, then you'll see far less people simply calling back. I find it difficult to imagine how this is less efficient. The average non transport job takes me about 30-40 mins (Not terrible different to my average on scene times of 20-30 mins for a transport). Total time for an average quick transport job is at least 90 mins, if its out of town (I work rural) the job can take up to 5 hours. Not to mention that you take up a hospital bed, and the time/resources of the ED as well as the ambulance service.

3: Their medical problem. Granted we have far less ability to fix those on scene, treat and release. Above and beyond primary care referral and OTC/pharmacy only meds. But I think there is value in fix and transport. I can think of plenty of patients I've seen that would have gone into resus had they self presented (or presented via "BLS" if we had that), but due to our ability to treat aggressively with both medications and common sense, went straight out into the waiting room. Resources wise, it makes sense. If you think of yourself as part of the healthcare system and not as a private company (granted you are actually all private companies in the US I guess).

I believe the OP's service is more primary-care-oriented than USA is, they can do different things and they have a different philosophy.

A little. I think its more the culture of allowing common sense here. The origins of US EMS is (as I understand it) very much routed in minimal training, protocol and medical direction. Add that to a hyper litigious society and I can see why you get the system you have. Here we thankfully have a culture where common sense, and thinking, autonomous clinicians is/are allowed and encouraged. Allowed perhaps by the absence of litigation more than many things. In terms of formal primary care arrangement, we're not particularly advanced.

We do however have two programs on the go that show a lot of promise:

1: REFCOM" - Calls that come through that could be predicted to be of low acuity and that probably need primary care rather than an ambulance are forwarded to specially trained paramedics after the initial call taking process. The paramedics can assess a person over the phone and recommend/organise more appropriate primary care pathways. The program has been immensely successful moving thousands of BS jobs to more appropriate pathways with almost no risk. The only problem I know of with REFCOM is that their isn't enough of it.

2: Field referral: This is a more formalised version of what many paramedics, myself included, already do. It involves care plans and referral to more appropriate care pathways on scene with a pt. The difference with the formal system is that it offers extra resources to provide better access to primary care and a certain amount of protection as part of a formal system, should mistakes get made. I think this shows a lot of promise and its expansion is a big part of the future of our profession.

 

[Handsome Robb]

great example. Let me ask another question: was her inhaler not functioning properly, or was the medication in it (typically albuterol) not relieving her wheezing? If it's the former, than your example is the rarity, not the norm. if it's the latter, than the albuterol isn't working, and I'm thinking solumedrol and maybe epi since the first line med isn't working. Or even better, now that you have fixed her with your meds, when she has another attack, her inhaler still won't help, and guess what the next call will be? you are going back to help her.
sounds great, but if they want to go to the hospital, are you going to tell them no? plus if they have minor cuts and scrapes, why on earth did they call an ambulance?
it has nothing to do with being lazy; most patients in my system don't need a hospital. but they still want to go. what will your bosses say if you start telling people you won't transport them, even if they want to go to the hospital?
and after you spend 20 minutes convincing them they don't need an ambulance, instead of 5 minutes transporting them to the ER, which has been a better use of your time? But your right, I could tell her exactly what you just said. and if she still wants to go.....
ahh level 0.... when you are are level -8 (that's 8 jobs holding with 0 units available) for 6 straight hours, then come talk to me. And yes, please don't bring up "well that's what mutual aid is for" management has decided we are not to use it for BLS calls, not my call, people who make more money than I made that decision. And yes, we should have more units, but don't have the funding for them (again, above my paygrade).lazy, what the bosses want, what is less potential litigious exposure for the provider, making the best use of my time, call it whatever you want. Doesn't mean your right, just what you are calling it.

If they call for an ambulance, requesting transport to the hospital, even if its for a reason that I don't think warrants it, than I will assist them to the truck, and transport them to the ER, as they are requesting. If you want to talk them into RMAing, that's on you.

She's an individual case that further discussion isn't appropriate for this thread. If you really want to talk about it I'm happy to answer your questions or discuss it further in PMs.

I never said I would deny anyone transport. I don't have a protocol for that. Like I said I always tell people I'm happy to take them to the hospital and if that's where they want to go I'll gladly take them there and put them in triage just like I told them would happen. At the same time I'm not in the business of talking people into going to the hospital that don't need to for reasons I've already cited. You said it yourself, to each their own, I have my style you have yours. I'm not going to talk to a patient about alternate plans unless I'm confident they do not need an ER. You can argue I'm opening myself up to a lawsuit all you want but in the end I gave them the necessary information to make an informed decision. I didn't tell them no, I told them the truth and then they made their own decision off of that information. I did not once tell them I would not transport them.

It hardly takes 20 minutes to "convince" someone they don't need an ambulance. Even if I know someone is BS I'm not going to just swoop them and run to the hospital. I still have information I need to obtain for my paperwork as well as an assessment to pass on the hospital whether they go to a room or triage we still give a report to the respective RN. Transport or not we average 10-20 minute scene times. If I transport that adds another 5-15 minutes depending on where we are and where we are going (could be upwards of 30 minutes if we are in an outlying valley or traffic is bad) as well as an additional 15-20 minutes at the hospital to a total of 50 minutes to one hour for a single transport in good conditions. Sure we can turn them around faster, especially if we are close to the hospital but with busy hospitals we can't just show up drop someone off and run away in 5 minutes. I'm not saying every transported call takes 60 minutes but generally that's about how long they take.

So with a transported call sitting at ~50-60 minutes how long does that AMA take me when I cut the transport and hospital time out of it? 20-30 minutes. Last time I checked 20-30 minutes is less than 50-60 minutes. Again, I have my own style and you have yours.

People that call 911 aren't always requesting transport as Melclin pointed out. There are plenty of cases that the caller has run out of options, ideas of what to do or how to cope with the situation as Melclin puts it. Just because someone calls 911 doesn't mean they want to go to the hospital, it means they want help. If that help is wanting/needing a ride to the hospital then by all means I'll make it happen. There are plenty of cases that the hospital isn't the answer and I'm happy to help provide information or guidance to find a solution for their problem. Of course plenty of people call with the sole goal of going to the hospital and nothing we say or do, no matter their condition or lack thereof will change their mind.

If you consistently have calls pending I'm surprised the citizens you serve tolerate it. If I were paying for or was told I had access to EMS coverage, especially in an urban setting, and this was the case I'd be pissed. I guess you guys aren't held to the same standard we are? We are required to maintain a 90% compliance rating when it comes to response times per county policy. If we dip below that for a month our contract goes up for grabs to the highest bidder and trust me, there are agencies out there looking to take that contract.

We are currently looking into options of an APP program such as Wake County EMS in North Carolina or MedStar in Texas do to deal with these calls that we are debating/arguing/bickering about. Until that happens we have to deal with the situation in the only way we can. I know for a fact that I'm not the only person at my agency or any other agency that uses a similar speech as mine. I know I'm not alone in my thought process but everyone is entitled to their own opinion.

This is a definite possibility. Our policy is that we are not a pharmacy on wheels. If we give you meds, then we transport. The exception is D50/oral glucose for hypoglycemics and sometimes albuterol for asthmatics. The reason for this is that we don't want people calling us because they are too lazy to refill their meds and then when they need it, just call us to come give some to them. But once in awhile, we all make mistakes and if it's not a frequent patient, or it's a transient person (I came to the state park and forgot my albuterol and now I'm on my way home to get it) we might give it at paramedic discretion.

Agreed, I'm not a mobile pharmacy. If I'm into a protocol/situation where I deemed it necessary to give you medications you bet more often then not we are going to the hospital and if you try to AMA I'm going to spend a lot of time trying to talk you into going to the hospital for further evaluation by a physician. With that said the two situations you stated, hypoglycemia and asthmatics, are the calls that come to mind that I have no problem with treating and releasing AMA when it comes to giving medications. Asthmatics don't always need a hospital despite what the EMT-B curriculum says. That's not directed at you WuLabs, just a general statement.

 

[DrParasite]

Melclin, I should rephase my initial comment about transporting everyone. I transport any one who wants to be transported, regardless of complaint. If they don't want to be transported, sign the RMA form. but in my experience, most medical complaints want to go to the hospital (the exception being seizure calls where the person has a history and a panicing friend/coworker calls, and diabetics whose BGL falls and now they are cold clammy not responsive) and if you can't fix the trauma on scene, off to the ER they want to go. If someone is borderline on whether or not they want to go, most of the time i say lets go to the hospital. I do know some people that will try to RMA every patient, regardless of if the patient wants to go or if the patient should go to the ER....

This is a definite possibility. Our policy is that we are not a pharmacy on wheels. If we give you meds, then we transport. The exception is D50/oral glucose for hypoglycemics and sometimes albuterol for asthmatics. The reason for this is that we don't want people calling us because they are too lazy to refill their meds and then when they need it, just call us to come give some to them. But once in awhile, we all make mistakes and if it's not a frequent patient, or it's a transient person (I came to the state park and forgot my albuterol and now I'm on my way home to get it) we might give it at paramedic discretion.

what he said.

It's different depending on where you are. In my suburban department, this is a load and go situation, where we have patient hop up onto the bench seat, strap them in, vitals en route, and report enroute. In a rural area, 15 minutes telling them they probably don't need to go will save you an hour and a half. Yes, treat what you have in front of you and not what might come later, but what you have in front of you doesn't need an ER.

I must admit, my experience is solely in urban and suburban systems. the rules for operating in a rural system might be different.

If they really want to go, I'll take them, but if they are not sure or I can convince them that they don't need an ER, that's also worth a shot. Remember that providing good patient care is a holistic thing. IF they don't need an ER, why subject them to that bill? As medical professionals, it's our job not only to provide them medical service, but also identify to them when certain services are not necessary for them.

as I said before, most people I transport don't need an ER. they don't even need an ambulance. but they want the ride to the ER in the ambulance, and I can assure you my boss would be much more unhappy with me if didn't take someone to the ER who wanted my services (or talked them out of it) than if I just followed their wishes and took them to the ER.

She's an individual case that further discussion isn't appropriate for this thread. If you really want to talk about it I'm happy to answer your questions or discuss it further in PMs.

no, that's ok. but you get where I was going right? as WuLabsWuTecH, we don't like acting as a mobile pharmacy. if the medications aren't working, than there is the possibility that stronger medications may be needed. and they don't have their own inhaler with them (for whatever reason), than we are just enabling them and acting as their mobile pharmacy.

Even if I know someone is BS I'm not going to just swoop them and run to the hospital. I still have information I need to obtain for my paperwork as well as an assessment to pass on the hospital whether they go to a room or triage we still give a report to the respective RN.

my initial assessment can take less than 5 minutes. my ongoing assessment, as well as the completion of most of my chart, can all be done in the back of the ambulance while we are going to the hospital. and for those that hug the wall in the ER for hours, that's even more time to finish your chart.

So with a transported call sitting at ~50-60 minutes how long does that AMA take me when I cut the transport and hospital time out of it? 20-30 minutes. Last time I checked 20-30 minutes is less than 50-60 minutes. Again, I have my own style and you have yours.

People that call 911 aren't always requesting transport as Melclin pointed out. There are plenty of cases that the caller has run out of options, ideas of what to do or how to cope with the situation as Melclin puts it. Just because someone calls 911 doesn't mean they want to go to the hospital, it means they want help. If that help is wanting/needing a ride to the hospital then by all means I'll make it happen. There are plenty of cases that the hospital isn't the answer and I'm happy to help provide information or guidance to find a solution for their problem. Of course plenty of people call with the sole goal of going to the hospital and nothing we say or do, no matter their condition or lack thereof will change their mind.

you are right, and I have restated my position.

If you consistently have calls pending I'm surprised the citizens you serve tolerate it. If I were paying for or was told I had access to EMS coverage, especially in an urban setting, and this was the case I'd be pissed. I guess you guys aren't held to the same standard we are? We are required to maintain a 90% compliance rating when it comes to response times per county policy. If we dip below that for a month our contract goes up for grabs to the highest bidder and trust me, there are agencies out there looking to take that contract.

while slightly off topic, I am told the city pays for 4 ambulances 24/7. We provide them with 4 24/7 trucks, 4 12 hour power trucks, and 4 or 6 transport capable ALS trucks (that cover 3 urban cities, and are backup to 2 others). We constantly run in the red, since many people don't have insurance. And no one else will take over the contract, because the city would be a money loser for any for-profit company.

I have been told that people complain about ems response times all the time; however, until the city pays for more trucks (they pay for 4, they are getting 13 plus support units), responses delays will remain the same. after all, you get what you pay for (or in our case, the city gets a really really sweet deal for what they pay for).

 

[Melclin]

If you consistently have calls pending I'm surprised the citizens you serve tolerate it.

...

We are currently looking into options of an APP program such as Wake County EMS

...

Asthmatics don't always need a hospital despite what the EMT-B curriculum says. That's not directed at you WuLabs, just a general statement.

Maybe they don't know. If people really knew how screwed up some aspects of our service were, they'd be happy to pay a little extra to fix it.
...
Sounds very interesting. Do you have any info on your system's interests or the other programs you mentioned that aren't on their website. A quick google didn't tell me too much. Other than the fact that it involved 200 didactic hours, which doesn't seem like enough, esp considering the low level of baseline education. I love the paramedic practitioner model and I think I'd actually really enjoy working in that role.
...
I've traditionally been wary of leaving asthmatics. Do you mind taking the conversation up in PM? I'd like to hear a little more about your pt and thoughts on non transport of asthmatics if you've got the time and the interest.

Melclin, I should rephase my initial comment about transporting everyone. I transport any one who wants to be transported, regardless of complaint. If they don't want to be transported, sign the RMA form. but in my experience, most medical complaints want to go to the hospital (the exception being seizure calls where the person has a history and a panicing friend/coworker calls, and diabetics whose BGL falls and now they are cold clammy not responsive) and if you can't fix the trauma on scene, off to the ER they want to go. If someone is borderline on whether or not they want to go, most of the time i say lets go to the hospital.

....

...but they want the ride to the ER in the ambulance

Why do you think that is? It seems common in these types of discussions for American EMTs to note that. What do you suppose the reasons might be for more Americans wanting a ride to hospital compared to the experiences we have?

I think your concerns about resource management and short scene times when you know you're going are quite legitimate. I my experience not transporting significantly increases resource availability, but there are a few pt types, the frequent fliers particularly where scene times are often under 3-5 mins because we know we're a taxi to those people. Its being dealt with by management at a higher level in the long term with the particular frequent fliers, but today we are a taxi.

In general if it is not true of your system to say that non transport reduces overall resource utilisation (I've noticed a lot of very very short turn around times at hospitals in some US systems) then I can certainly understand a wariness about non-transport. Ambulances being taken up for hours and hours getting involved in primary care issues is a legitimate concern. While it is a reality that we will get called to jobs like this, it is still up for debate as to how much we should get involved with lengthy management of this pt group (eith long transports or long scene times). There are very reasonable questions to be asked about resource availability for the big one (just for a busy system), added skill sets requiring new knowledge leading to the inevitable argument about more pay, as well as skill dilution and reduced downtime adding to stress and burn out.

**** TO EVERYONE****​

This idea of people assuming/wanting a ride to the ED from EMS is very common in these discussion on this board, but it seems to be uniquely American (or at least different to my experience here in Aus). Do people have any suggestions on why more Americans might want a ride to hospital than perhaps Australians do (assuming that my statement is true in the first place and not just a result of a faulty conclusion)?

--->>I might suggest the following two reasons as possibilities:

1. We have free access to primary care doctors and many other kinds of medicine as part of our universal healthcare. Given that people can and do attend GPs for free in many cases, this may reduce the number of people presenting to EDs for primary care reasons/primary care problems that are now emergency problems through lack of PCP manangement. This doesn't explain why they do it via ambulance though.

Is it because they think they'll get in quicker? How common is that notion amongst your patients? Its Extremely common amongst mine.

2. I have noticed that many American providers are, perhaps rightly given the systems they work in, wary of discussing a diagnosis with the patient (I hate the old saying, "We don't diagnose". Absolute rubbish to core). How common is it for you to sit down at the end of your assessment and say,
"Look I think the problem is X, for Z and Y reasons. X is very common in your age group and people with your symptoms the way you describe them. Its also possible problem N is contributing but I can't tell with the tools I have here. There is about a 2% chance that N in part of the problem in which case going to the ED is a good idea but not essential. Does that sound right to you? You understand everything I've said? Okay, given what I've just said, I think we should go ahead and do A if you're comfortable with that. How do you feel about doing A?"
etc etc . It seems like its possible that people often want to go to ED because ambulance providers haven't actually told them anything about their condition, its expected clinical course and probable investigations/treatments required. If you wheel the stretcher in during the first 5 mins, have an IV in them before you know their name and roll them in the door before the commercial break is over, are you perhaps contributing to a culture amongst patients/a public mindset where they assume transport from EMS?

 

[mycrofft]

Melclin, great comment and good observations.

If you are a "street" tech, discussing diagnoses or explaining your thought process will get you in trouble, and part of that (the non-political and non-historical part) is that the training level isn't that high. If a doctor makes a mistake, its "Whoops" If a tech (EMT, paramedic etc etc) does that, it's malpractice.

The American experience is to be told "Call 911 if anything happens", and when they arrive it is expected that the full diagnostic resources of a hospital are required to rule out or in all the possibilities. Any hospital will tell you that's right.

We have a large wedge of our population, mostly urban and lower income to downright poor, who use ER's for their medical needs period, and since they may (often) wait long hours in squalid waiting areas, they develop behaviors which make their prompt care more likely, such as coming in via ambulance, complaining of chest pain or shortness of breath, etc.

We also have an increasing population who have no car, no local friends or family to drive them to a hospital or clinic, the hospital is in a dangerous part of town (Los Angeles, are you reading this?), and no service to just get a ride with someone who will care enough to do it dependably and then wait around to return them.

We do not teach everyday individuals how to make any self-diagnoses (except in health nostrum ads) other than "IF you see this (or this or this or this), THEN you call 911 (and expect to see the ER), ELSE" you are negligent, stupid or obviously don't watch much TV.

 

[WuLabsWuTecH]

**** TO EVERYONE****​

This idea of people assuming/wanting a ride to the ED from EMS is very common in these discussion on this board, but it seems to be uniquely American (or at least different to my experience here in Aus). Do people have any suggestions on why more Americans might want a ride to hospital than perhaps Australians do (assuming that my statement is true in the first place and not just a result of a faulty conclusion)?

--->>I might suggest the following two reasons as possibilities:

1. We have free access to primary care doctors and many other kinds of medicine as part of our universal healthcare. Given that people can and do attend GPs for free in many cases, this may reduce the number of people presenting to EDs for primary care reasons/primary care problems that are now emergency problems through lack of PCP manangement. This doesn't explain why they do it via ambulance though.

Is it because they think they'll get in quicker? How common is that notion amongst your patients? Its Extremely common amongst mine.

2. I have noticed that many American providers are, perhaps rightly given the systems they work in, wary of discussing a diagnosis with the patient (I hate the old saying, "We don't diagnose". Absolute rubbish to core). How common is it for you to sit down at the end of your assessment and say,
"Look I think the problem is X, for Z and Y reasons. X is very common in your age group and people with your symptoms the way you describe them. Its also possible problem N is contributing but I can't tell with the tools I have here. There is about a 2% chance that N in part of the problem in which case going to the ED is a good idea but not essential. Does that sound right to you? You understand everything I've said? Okay, given what I've just said, I think we should go ahead and do A if you're comfortable with that. How do you feel about doing A?"
etc etc . It seems like its possible that people often want to go to ED because ambulance providers haven't actually told them anything about their condition, its expected clinical course and probable investigations/treatments required. If you wheel the stretcher in during the first 5 mins, have an IV in them before you know their name and roll them in the door before the commercial break is over, are you perhaps contributing to a culture amongst patients/a public mindset where they assume transport from EMS?

1) in the urban area, this is a huge thing. people know they can get free care at the ED. The free clinics that operate in my area operate one evening a week, and they don't give pain meds for the most part.

We don't see this as much my suburban area--it's usually a daughter or SO pressuring a family member of being seen when they keep putting off doctors appts or such. These patients usually do have something wrong with them and by threatening to call 911 (or actually calling us) they can usually convince Daddy to make the appointment or to go with us and get checked out. We have on many, many occasions actually found an abnormal EKG or other issue that needed to be fixed so I don't mind this "abuse" of the 911 system at all. As we tell people, if you're unsure, call! I'd rather go out for some BS now than for some OS later. We get a lot of refusals from suburban families who want to drive Daddy or Sister etc to the hospital themselves, but us going there convinced them to agree to go to the ER.

In the rural area I work in it just varies. Some are more like the urban "I want a ride" and other are more like the suburban "can you check grandpa out?"

Not to stereotype at all, but this is just what I see as common in different places.

1.5) This is a very common notion. Many patients assume they will be seen first in which many cases is true, but for patients who I know are BS, we'll usually tell them the pt is "triage appropriate" so that the patients will learn that they don't get in quicker. This is done systemwide as we have found it is effective to reduce the BS calls.

2) We don't do it in the city. We may offer suggestions en route to the hospital, but nothing more to the patients. The rural medics I work with well preface with "I'm not a doctor and I don't have all the capabilities of a hospital, so this is just a guess, but if you were to ask me for a guess as to what is wrong, I think..."

I do find that with the older medics that say this, they tend to get more refusals than the newer medics who don't "pseudo-diagnose" on scene. I'll try to find stats the next time I'm in station b/c we do keep stats on who gets how many refusals and their percentages.

 

[EpiEMS]

Don't forget - people often think that an ambulance transport will get them seen faster by the physician or PA on duty at the ER. It shouldn't. At least, unless ambulance transports were only for serious cases, then, maybe, it'd be worthwhile to fast-track.

 

[WuLabsWuTecH]

Don't forget - people often think that an ambulance transport will get them seen faster by the physician or PA on duty at the ER. It shouldn't. At least, unless ambulance transports were only for serious cases, then, maybe, it'd be worthwhile to fast-track.

And this is why all the medics and squads in our system make sure to identify "triage-appropriate" patients when possible. We are trying to teach those BS patients that they have to wait just like everyone else!

 

[RocketMedic]

I'm not a fan of transporting everyone. If they want to go, I'll happily transport them, but I'm not one to sugarcoat the bill and the potential to go directly to triage.

Patient's choice.