Pre-Hospital physicians

[EpiEMS]

If I were putting together a physician scene response program, my question would be:

Who's paying for it? Unless you can justify efficacy (and cost/benefit), it isn't reasonable to make patients pay for it.

 

[NysEms2117]

If I were putting together a physician scene response program, my question would be:

Who's paying for it? Unless you can justify efficacy (and cost/benefit), it isn't reasonable to make patients pay for it.

Be like the lovely Albany ER docs and have them volunteer

 

[EpiEMS]

Be like the lovely Albany ER docs and have them volunteer

There ain't no such thing as a free lunch
(Are they driving personal vehicles?)

 

[NysEms2117]

There ain't no such thing as a free lunch
(Are they driving personal vehicles?)

I know was half kidding. But I'd imagine the fact they don't want extra pay for actually providing the service helps a lot. If i'm not mistaken the Albany county sheriffs office EMS unit pays for the vehicle(since it was their idea), however it is printed with albany med stickers and what not. When i go to EMS work again i'll ask the Docs, who pays for gas and little things like that to get your full answer ! *no sarcasm meant, i will genuinely get your answer lol*

 

[EpiEMS]

@NysEms2117 I'd be very curious to hear about the operational (and financing) aspects of the program!

Not wanting pay is probably the biggest help they can provide on a cost front, but I have to imagine that you can't really get enough physicians to be willing to do that everywhere to make a system workable.

 

[NysEms2117]

@NysEms2117 I'd be very curious to hear about the operational (and financing) aspects of the program!

Not wanting pay is probably the biggest help they can provide on a cost front, but I have to imagine that you can't really get enough physicians to be willing to do that everywhere to make a system workable.

not everywhere but all at albany med are in agreeance, PM me with a list of deets you want to know and ill ask

 

[cruiseforever]

I work for two services. Each one has medical directors that will respond to calls if they are close or if it sounds like a call where their services maybe useful. One service provides it's MD with a vehicle. The other responds in his own vehicle. There is also a medical director for the West Metro system that is on call for MCIs and other special needs.

 

[NPO]

Our medical director will sometimes finish his shift in the ER and jump on the ambulance. He mostly does it for observation, but should you need any orders you could ask. He's a very progressive doctor, so he'd probably be willing to give some ridiculous orders if he's in the ambulance with you.

But that's as far as our field doctoring goes.

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[VFlutter]

Our Medical Director will fly with us pretty regularly.

Although not pre-hospital we are doing retrieval ECMO. We will pick up the CT surgeon and equipment then fly to the referring hospital and place the patient on ECMO in their OR and fly back. Can be very stressful and a long chart however it is an awesome experience not many providers get to do.

I do like the saying that many of these hospital are like "well lit scene calls"

 

[MonkeyArrow]

Although not pre-hospital we are doing retrieval ECMO. We will pick up the CT surgeon and equipment then fly to the referring hospital and place the patient on ECMO in their OR and fly back. Can be very stressful and a long chart however it is an awesome experience not many providers get to do.

Why not just transfer the patient to the tertiary care center?

 

[VFlutter]

Why not just transfer the patient to the tertiary care center?

This is for patients that are too unstable to transfer and would likely die otherwise. The last patient was on 100% Fi02, 20 of PEEP, Inhaled Nitric Oxide, and prone with saturations in the 60s.

 

[Handsome Robb]

Why not just transfer the patient to the tertiary care center?

My guess would be improved outcomes with earlier ECMO placement? But that's truly a shot from the hip.


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[VFlutter]

My guess would be improved outcomes with earlier ECMO placement? But that's truly a shot from the hip.


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This too. Outcomes seem to be better with early and aggressive ECMO placement rather than treating it as a salvage therapy. They are placing influenza patients on VV ECMO pretty quick now.

 

[VentMonkey]

They are placing influenza patients on VV ECMO pretty quick now.

How far into the SIRS/ sepsis cascade are these folks specifically? I would venture to guess at least with a moderate PaO2/ FiO2 ratio?

 

[EpiEMS]

I do like the saying that many of these hospital are like "well lit scene calls"

Why's that? Is it because of a lack of critical care capabilities at the hospitals you're picking up from?

They are placing influenza patients on VV ECMO pretty quick now.

Geez, and I thought the lack of ventilators was gonna be the big pandemic rationing issue! This'll be a whole other level of rationing.

 

[Tigger]

I do like the saying that many of these hospital are like "well lit scene calls"

It seems like half the sick patients I run on are coming out of our critical access hospital. We have minimal ground CCT availability and they're a little too close for routine flights, so here we are.

 

[VFlutter]

Why's that? Is it because of a lack of critical care capabilities at the hospitals you're picking up from?

Usually the expectation of an ER/ICU transfer is that most primary interventions are already done and you are just transferring to your equipment, making minor adjustments, and heading on your way. However some of these rural critical access hospitals are staffed by non-EM Physicians with Anesthesia on call potentially 30+mins away. It is not uncommon to show up to an unresponsive hypotensive peri-arrest patient being bagged with inadequate IV access etc so you are having to start from square one.

Geez, and I thought the lack of ventilators was gonna be the big pandemic rationing issue! This'll be a whole other level of rationing.

ECMO equipment is becoming much more available, portable, and somewhat more affordable (The circuits are still crazy expensive). Many institutions use Thoratec Centrimags for everything so they get a lot of utility out of them. Depending on how you cannulate, plus or minus and oxygenator, you can use the same set up for LVAD, RVAD, VV or VA ECMO.

 

[EpiEMS]

However some of these rural critical access hospitals are staffed by non-EM Physicians with Anesthesia on call potentially 30+mins away.

I was just reading about Medicare's standards for CAHs, and it's enough to make me want to stay in a nice urban bubble...no requirement for an EM-boarded physician, etc...

 

[rescue1]

If I remember correctly, it's still close to 50% of EDs that are staffed with family medicine or internal medicine doctors. Obviously they're mostly rural, but even where I worked in suburban PA (30 minutes from downtown Philadelphia) there were EDs that had family doctors working.

 

[EpiEMS]

@rescue1, that's mindblowing considering that they even have PA EM residencies now!


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