Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 You describe a situation that I have experienced from the other side of the fence. We had a doc that was not exactly the most thorough in his duties. Frequently, he would only treat a portion of the problem, and there would be returning patients. Try doing a survey and check for trends (certain docs, certain days, etc.). If there is a correlation, take it to the hospital's administrator. If that doesn't work, try the BME. JCAHO considers ER returns a sentinel marker. If you can read this, thank a teacher If you can comment freely on this, thank a soldier Larry RN LP EMSI Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 Mr. Grady, We get calls to transport someone who had just been released from the ER back again on a fairly regular basis. However, in almost all cases, it is because the patient hasn't followed the instructions and advice they were given the first time. Hasn't gotten the prescriptions filled, got one prescription filled but not the other, took one dose 15 minutes ago and it hasn't worked yet, wants an instant-fix instead of giving the meds time to work, didn't have a ride to the pharmacy, was told " bed rest " but hasn't done it, and on and on and on. The most extreme example of what we see: An elderly woman who had arthritic pain and wanted to go to the ER. She was hurting, nothing was working, and she was adamant--she wanted to go to the hospital! Didn't tell us about her trip to the ER the evening before. When we arrived at the ER, she got the same nurse who had cared for her on her last visit. The conversation went something like this: Nurse: " Did you take the medicine we prescribed for you? " Patient: " No. " Nurse: " Why not? " Patient: " I was worried about taking it because I've never taken that medicine before. " Nurse: " If you take that medicine, your pain will be better. " Patient: " Really? " Nurse: " Really. " Patient: " Okay " , and got off the bed to go to the desk to sign herself out. We did have a case recently where the hospital may have missed something on the patient's first trip (by ambulance). We transported her a second time later in the same day. On both visits, all of her complaints and symptoms were addressed. However, on her second visit, as her discharge paperwork was being done, her condition suddenly worsened. Based on new symptoms and signs she was exhibiting, new tests were done and a problem was discovered that literally could have resulted in her death within a few hours if it hadn't been found. However (again) if the hospital ran into the same problems that we did, I can understand how they might have missed something both times. The patient didn't speak English and other adults at the scene were translating. On both calls, the crews were lied to, conflicting information was given, they wouldn't answer some questions, the patient wouldn't answer some questions, they were rude and uncooperative to the extreme. The problems went on and on. Being one of the people on the first call, I can assure you that the questions that were being asked, and the information that was being requested, by EMS were not unreasonable. We did everything we could to do the proper assessment and history, and we cared for the patient to the best of our ability under the circumstances. However, we were stonewalled at every turn. Only speculation on my part, but I suspect that the hospital staff ran into the same problem. Maxine Pate hire-Pattison EMS ----- Original Message ----- Again and again, we are called to transport medical patients to one of the ERs that we feed into, and again and again the patients beat us home. Do any of the rest of you experience frustration with the services and treatment that your patients receive in the ERs that you transport to? Mr. Grady Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 Gene, This idea is a FANTASTIC one and one that we are looking at doing as well....but here is the rub....nobody will pay EMS for it if we don't turn tires...how about, put her in the ambulance, take her around the block, give her the Phenergan, and deliver her to Patient Residence ER.....maybe then somebody would pay for it. The reimbursement issue is one gig that has always stopped primary care initiatives.... Dudley Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 How about a system that would allow EMT's such as ourselves, to go to that pt's house, provide that phenegran which would cause her current problems to subside, and then perform a follow up later that evening or early the next morning. We would be treating the problem, and we could provide type of checks and balances system, where we would be able to see if our treatments were needed and if so, what kind of definitive results were obtained. Had any type of EMS system done a study on this, and if so, what kind of results were there? -TXNREMT-I > Gene, > > This idea is a FANTASTIC one and one that we are looking at doing as well....but here is the rub....nobody will pay EMS for it if we don't turn tires...how about, put her in the ambulance, take her around the block, give her the Phenergan, and deliver her to Patient Residence ER.....maybe then somebody would pay for it. > > The reimbursement issue is one gig that has always stopped primary care initiatives.... > > Dudley Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 I have to ask, what difference is there from this issue and service initiated refusals. I may be flamed for this but I do not feel, at this time, that ambulances or their staff are equipped to rule out the need for a physician evaluation. There are a few studies that support this position. I realize that there are many cases in which patients are sent home from the ED faster than the crews return to the station but I am concerned about the many more times when we transport patients that don't look too bad but they end up admitted to the hospital for serious health problems. I just do not think we have the tools or resources to provide that level of assessment. Steve Dralle San , TX Re: Why go to the ER? How about a system that would allow EMT's such as ourselves, to go to that pt's house, provide that phenegran which would cause her current problems to subside, and then perform a follow up later that evening or early the next morning. We would be treating the problem, and we could provide type of checks and balances system, where we would be able to see if our treatments were needed and if so, what kind of definitive results were obtained. Had any type of EMS system done a study on this, and if so, what kind of results were there? -TXNREMT-I > Gene, > > This idea is a FANTASTIC one and one that we are looking at doing as well....but here is the rub....nobody will pay EMS for it if we don't turn tires...how about, put her in the ambulance, take her around the block, give her the Phenergan, and deliver her to Patient Residence ER.....maybe then somebody would pay for it. > > The reimbursement issue is one gig that has always stopped primary care initiatives.... > > Dudley Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 I think as long as a patient medically requires ambulance transport, we are obligated to provide those services, regardless of our opinion of what someone else should have done. Whether or not care provided in the ER is appropriate is not our responsibility. And, you are likely going to open a big can of worms if you start accusing your colleagues in emergency medicine of under-treating. But, if you feel strongly that a patient's care is inappropriate, you should report it to hospital administration. I think there are just too many variables to set up protocols for treating patients at home without transporting to the hospital. Look at it this way. When a patient calls the ER wanting to know what to do about a problem, what are they told every time, " You need to come in and be seen. " I don't think hospitals would be willing to take on the liability of giving us treatment instructions without bringing the patient in. I also don't think EMS organizations are ready to take on the liability of determining that a patient does not need to be transported when it is so much safer to just recommend transport every time and let the patient decide. There is always the option of treating on scene, then the patient refusing transport before being loaded, however, the service cannot bill for a nontransport. Besides, it usually takes just as much time assess and treat on scene as it does to treat in route to the ER. However, there is even more paperwork involved if you treat on scene, but do not transport (refusal forms, extra documentation to explain no transport, etc.). As far as the specific situation at hand, this patient had a legitimate medical complaint that needed to be addressed. Since the ER had failed to provide a remedy for the nausea in the initial visit, it would be impossible for the patient to take her antibiotics. This call should be covered by Medicare or other coverage. If she is not insured, don't feel bad because she is going to get a bill. She is the one choosing to go by ambulance; she can accept the responsibility of paying her bill. Plus, you, Mr. Grady, made the decision to treat her at the ALS level, so you are the one responsible for the higher charges. Besides, by treating her in route to the hospital, you certainly justified the need for ambulance transport. And since you made her feel better, you should take pride in knowing that you got to use the knowledge and training that you received in paramedic school to fix a patient's problem. After all, isn't that why we got into this business. Here is one option for this particular situation. Depending on the time of day, the patient could have called the ER and had the physician who treated her call in a prescription for Phenergan suppositories. Bullard LP _____ From: wegandy1938@... Sent: Monday, June 14, 2004 4:05 AM To: Subject: Why go to the ER? We are called to the home of an 80 year old patient who was seen earlier today in an ED for fever, chills, nausea, vomiting, flank pain, and undiffierentiated pain in many other areas. This patient has had stints placed 3 years ago, takes meds for arthritis, hypertension, osteoporosis, anxiety, depression, and anticoagulants. She was diagnosed in the ED with a kidney infection and discharged with a prescription for Levaquin, nothing for nausea, and no followup instructions. She had taken her Levaquin as prescribed and vomited it up. She had vomited to the point that she was experiencing severe abdominal pain, and she was weak and really distressed from the nausea. She was hurting. She felt like she was going to faint at any moment. Her vitals were OK but she was in obvious distress from the nausea. Her daughter was adamant that we take her back to the hospital from whence she had come earlier today. Now, what were we to do for this patient? There was nothing to do but to transport her back to the ED from whence she came, give some promethazine for the nausea enroute, and deliver her back to the ER. After administration of the Phenergan, she got better and the nausea stopped. I'm sure that she was once again released almost immediately and almost beat us home. If there was an intelligent system of alternative care we would not have transported her back to the ER at all. We would have given the Phenergan, left instructions to call us if things got worse, talked it all over with a medical director physician who was available to us by cellular, and spared our patient the expense of an ambulance transport that cost her more than $600.00. Again and again, we are called to transport medical patients to one of the ERs that we feed into, and again and again the patients beat us home. Again and again, we are called to take them to the ER a few hours after they were discharged from the ER that we took them to a few hours before, and they are sicker than they were before. Invariably we find that the treatment that they received in the ED was inadequate, and if they had received the right care in the first place we wouldn't be taking them back. The cost of these re-transports when considered as something that happens all over the country every day, many times a day, is immense. The cost must be absorbed by the EMS service that does these unneeded transports, and it also falls on the hospital who once again have to deal with patients that ought not have come back to them. Why have we not developed a system that allows EMTs and Paramedics to take care of the needs of patients in the field and avoid placing patients who don't need to be seen in the hospital in the ER? Do any of the rest of you experience frustration with the services and treatment that your patients receive in the ERs that you transport to? Please post your experiences. And if you have experiences that are really positive, please also post those. I want to know if there are ERs that I would want to go to. Mr. Grady Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 Comments inline > I think as long as a patient medically requires ambulance transport, we are > obligated to provide those services, regardless of our opinion of what > someone else should have done. I don't believe that's in question here. > Whether or not care provided in the ER is > appropriate is not our responsibility. And, you are likely going to open a > big can of worms if you start accusing your colleagues in emergency medicine > of under-treating. But, if you feel strongly that a patient's care is > inappropriate, you should report it to hospital administration. > > > > I think there are just too many variables to set up protocols for treating > patients at home without transporting to the hospital. In certain circumstances, this is true, there are however, circumstances where treatment at home, and a signed refusal are fine. You can't generalize all calls into one category or the other. There are also times when the patient doesn't require ambulance transport, they need a cab or a bus. The responsibility comment is a whole 'nother thread. Look at it this way. > When a patient calls the ER wanting to know what to do about a problem, what > are they told every time, " You need to come in and be seen. " No, that's why many facilities, especially in larger metro areas have 'Dial-A-Nurse' where you can contact a nurse via telephone, give her/him the signs and symptoms, and make an intelligent decision between the two of you > I don't think > hospitals would be willing to take on the liability of giving us treatment > instructions without bringing the patient in. Hospital in and of themselves don't dictate how I treat my patient anyway, that's my Medical Director's job. My Medical Director has already taken on the liability of giving me treatment instructions and guidelines which apply with or without transporting, they're called protocols. so don't think EMS > organizations are ready to take on the liability of determining that a > patient does not need to be transported when it is so much safer to just > recommend transport every time and let the patient decide. This is a pet peeve of mine. I'll give the latitude of saying that most patients with SOB, or chest pain, or other issues that lend credence to them having a serious underlying medical condtition, should be transported. There are however, a certain percentage of the patients that we see, who are requesting transport solely because they do not have transportation. This is neither a medically necessary ambulance transport, nor is it judicous use of your resources. There is always > the option of treating on scene, then the patient refusing transport before > being loaded, however, the service cannot bill for a nontransport. Besides, > it usually takes just as much time assess and treat on scene as it does to > treat in route to the ER. However, there is even more paperwork involved if > you treat on scene, but do not transport (refusal forms, extra documentation > to explain no transport, etc.). I have to do the same report, it doesn't matter if I treat and transport, treat and don't transport, or don't do either one. > > > > As far as the specific situation at hand, this patient had a legitimate > medical complaint that needed to be addressed. Since the ER had failed to > provide a remedy for the nausea in the initial visit, it would be impossible > for the patient to take her antibiotics. This call should be covered by > Medicare or other coverage. If she is not insured, don't feel bad because > she is going to get a bill. She is the one choosing to go by ambulance; she > can accept the responsibility of paying her bill. Plus, you, Mr. Grady, > made the decision to treat her at the ALS level, so you are the one > responsible for the higher charges. The option was..........? Perhaps to treat her at a lower level of care? That's absurd! Talking about opening the liability door wide open.... Besides, by treating her in route to > the hospital, you certainly justified the need for ambulance transport. And > since you made her feel better, you should take pride in knowing that you > got to use the knowledge and training that you received in paramedic school > to fix a patient's problem. After all, isn't that why we got into this > business. Here is one option for this particular situation. Depending on > the time of day, the patient could have called the ER and had the physician > who treated her call in a prescription for Phenergan suppositories. > Why couldn't the Medic attending contact the ER physician? If the physician is willing to call in a prescription for Phengran, why couldn't the Medic administer it while they were there? That would save the patient a trip to the pharmacy. Mike Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 Steve, Your position is actually supported by at least one major study that showed a disappointingly low correlation between paramedic estimations of who would be admitted to the hospital and who actually was. The big differences come with medical patients who have conditions that we don't study and where lab tests are a big part of the diagnostic process. That is why I am so adamantly against service initiated refusals except in those cases like a mashed finger or stubbed toe that obviously don't need ambulance transportation. I NEVER no-ride a patient with any sort of even semi-significant medical complaints. Gene In a message dated 6/14/2004 9:17:45 AM Central Daylight Time, SDralle@... writes: I have to ask, what difference is there from this issue and service initiated refusals. I may be flamed for this but I do not feel, at this time, that ambulances or their staff are equipped to rule out the need for a physician evaluation. There are a few studies that support this position. I realize that there are many cases in which patients are sent home from the ED faster than the crews return to the station but I am concerned about the many more times when we transport patients that don't look too bad but they end up admitted to the hospital for serious health problems. I just do not think we have the tools or resources to provide that level of assessment. Steve Dralle San , TX Re: Why go to the ER? How about a system that would allow EMT's such as ourselves, to go to that pt's house, provide that phenegran which would cause her current problems to subside, and then perform a follow up later that evening or early the next morning. We would be treating the problem, and we could provide type of checks and balances system, where we would be able to see if our treatments were needed and if so, what kind of definitive results were obtained. Had any type of EMS system done a study on this, and if so, what kind of results were there? -TXNREMT-I > Gene, > > This idea is a FANTASTIC one and one that we are looking at doing as well....but here is the rub....nobody will pay EMS for it if we don't turn tires...how about, put her in the ambulance, take her around the block, give her the Phenergan, and deliver her to Patient Residence ER.....maybe then somebody would pay for it. > > The reimbursement issue is one gig that has always stopped primary care initiatives.... > > Dudley Yahoo! Groups Links Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 Thanks for all the great comments on this theme. Red River New Mexico tried a system for treating and releasing on scene several years ago and finally abandoned it. I'm not aware of all the reasons, but I'm pretty sure that one of them was lack of reimbursement. It's ironic, isn't it, that Medicare/Medicaid/HMOs will pay higher charges for a transport that you can wiggle into their reimbursement categories rather than paying a lesser amount for treat and street. The other problem that I see with treat and street is that the hospital needs to be a part of the decision making process. We certainly have the technology available to send real time video to a hospital and transmit other data to a physician who could be a part of the street and treat decision making and treating process. But liability issues will always keep meaningful processes like these from being implemented until we get legislation that protects everybody and allows this. I don't think the concept has had a fair trial yet, but I also don't see anybody standing in line to start doing it. Everybody screams about the skyrocketing costs of health care but nobody wants to risk having his level of reimbursement lessened. A hospital can be reimbursed for seeing the same patient that EMS will be refused reimbursement for. Makes no sense, does it? And finally, most medics are NOT, repeat NOT, ready to make the kinds of treatment decisions that would be necessary in these situations. The new curriculum goes part of the way toward giving them the tools to do this, but not all the way. And since few have chosen to actually teach the new curriculum in all its glory, the situation is perpetuated. As I have written before, the market for paramedics for this sort of education and training is driven by the big city fire department services and private contract services, and because of their close proximity to hospitals and short transport times, they would very seldom use the kinds of abilities that such an education would provide. They really don't need that sort of training. That's why the DOT adopted the Intermediate curriculum that's actually Paramedic Lite. As I understand it, the intention was that the Intermediate curriculum would serve the needs of those communities. In Texas, turf battles, battles over who would be called what, and other ego driven disputes caused meaningful Paramedic education to end up on the trash heap. So, bottom line: We're not ready for treat and street, although it might make sense in a certain percentage of cases. I see no prospect for any change on the horizon or beyond. Mr. Grady GeezerMedic IV " Champagne for my real friends, real pain for my sham friends. " --Tom Waits Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 _____ From: hatfield@... Sent: Monday, June 14, 2004 1:51 PM To: Subject: Re: Why go to the ER? Comments inline Text in red is copied from the original e-mail. > I think as long as a patient medically requires ambulance transport, we are > obligated to provide those services, regardless of our opinion of what > someone else should have done. I don't believe that's in question here. Again and again, we are called to take them to the ER a few hours after they were discharged from the ER that we took them to a few hours before, and they are sicker than they were before. Invariably we find that the treatment that they received in the ED was inadequate, and if they had received the right care in the first place we wouldn't be taking them back. Why have we not developed a system that allows EMTs and Paramedics to take care of the needs of patients in the field and avoid placing patients who don't need to be seen in the hospital in the ER? > Whether or not care provided in the ER is > appropriate is not our responsibility. And, you are likely going to open a > big can of worms if you start accusing your colleagues in emergency medicine > of under-treating. But, if you feel strongly that a patient's care is > inappropriate, you should report it to hospital administration. > > > > I think there are just too many variables to set up protocols for treating > patients at home without transporting to the hospital. In certain circumstances, this is true, there are however, circumstances where treatment at home, and a signed refusal are fine. You can't generalize all calls into one category or the other. You're right, you cannot generalize all calls into one category or the other, which is why you would have to have protocols dictating when and how to treat on scene but not transport. There are also times when the patient doesn't require ambulance transport, they need a cab or a bus. Good luck in court when the attorney for the plaintiff asks you why you told the patient he did not need an ambulance right before he coded in the cab. Now don't get me wrong. I see your point entirely, and I agree completely. But, everything in medicine is about CYA. There is a lot of liability in advising a patient that they do not need to go by ambulance. The responsibility comment is a whole 'nother thread. Look at it this way. > When a patient calls the ER wanting to know what to do about a problem, what > are they told every time, " You need to come in and be seen. " No, that's why many facilities, especially in larger metro areas have 'Dial-A-Nurse' where you can contact a nurse via telephone, give her/him the signs and symptoms, and make an intelligent decision between the two of you Sounds like a great idea. We don't have that in this area. Our ER nurses are not allowed to dispense advice over the phone without the patient being seen in the ER. Again, it's a liability issue. Now it's one thing if a patient calls and wants to know if they can take Tylenol while pregnant. But, if someone calls in complaining of shortness of breath, for example, the nurse is usually not going to tell them to take some Benadryl and a hot shower. But again, this must be a regional thing. > I don't think > hospitals would be willing to take on the liability of giving us treatment > instructions without bringing the patient in. Hospital in and of themselves don't dictate how I treat my patient anyway, that's my Medical Director's job. My Medical Director has already taken on the liability of giving me treatment instructions and guidelines which apply with or without transporting, they're called protocols. Again, a regional issue. In our area, protocols (which you assume I am not familiar with) are dictated by our medical director. However, our protocols do not cover every possible patient scenario (maybe yours are more thorough). If a patient does not fit a particular protocol or we want to deviate from protocol, we have to contact medical control for instructions. In this area, the receiving hospitals make any and all decisions regarding patient care that is not governed by protocol. If we are not transporting, these decisions go through our county ER. so don't think EMS > organizations are ready to take on the liability of determining that a > patient does not need to be transported when it is so much safer to just > recommend transport every time and let the patient decide. This is a pet peeve of mine. I'll give the latitude of saying that most patients with SOB, or chest pain, or other issues that lend credence to them having a serious underlying medical condtition, should be transported. There are however, a certain percentage of the patients that we see, who are requesting transport solely because they do not have transportation. This is neither a medically necessary ambulance transport, nor is it judicous use of your resources. Yes you are correct. But I don't believe the patient Mr. Grady described falls into this category. If you want to debate over the actual percentage of patients who go by ambulance and really, truly need an ambulance, my experience has been this would be a small number. There is always > the option of treating on scene, then the patient refusing transport before > being loaded, however, the service cannot bill for a nontransport. Besides, > it usually takes just as much time assess and treat on scene as it does to > treat in route to the ER. However, there is even more paperwork involved if > you treat on scene, but do not transport (refusal forms, extra documentation > to explain no transport, etc.). I have to do the same report, it doesn't matter if I treat and transport, treat and don't transport, or don't do either one. > Another regional thing. We have a separate refusal form that has to be filled out in addition to the regular run report. > > As far as the specific situation at hand, this patient had a legitimate > medical complaint that needed to be addressed. Since the ER had failed to > provide a remedy for the nausea in the initial visit, it would be impossible > for the patient to take her antibiotics. This call should be covered by > Medicare or other coverage. If she is not insured, don't feel bad because > she is going to get a bill. She is the one choosing to go by ambulance; she > can accept the responsibility of paying her bill. Plus, you, Mr. Grady, > made the decision to treat her at the ALS level, so you are the one > responsible for the higher charges. The option was..........? Perhaps to treat her at a lower level of care? That's absurd! Talking about opening the liability door wide open.... Mr. Grady seems to feel that this patient did not warrant ambulance transport. If this were the case, then BLS treatment would have been sufficient. My point was if she required the higher level of care, he should not feel guilty about the expense. I'm sure that she was once again released almost immediately and almost beat us home. Again and again, we are called to transport medical patients to one of the ERs that we feed into, and again and again the patients beat us home. The cost of these re-transports when considered as something that happens all over the country every day, many times a day, is immense. The cost must be absorbed by the EMS service that does these unneeded transports. Besides, by treating her in route to > the hospital, you certainly justified the need for ambulance transport. And > since you made her feel better, you should take pride in knowing that you > got to use the knowledge and training that you received in paramedic school > to fix a patient's problem. After all, isn't that why we got into this > business. Here is one option for this particular situation. Depending on > the time of day, the patient could have called the ER and had the physician > who treated her call in a prescription for Phenergan suppositories. > Why couldn't the Medic attending contact the ER physician? If the physician is willing to call in a prescription for Phengran, why couldn't the Medic administer it while they were there? That would save the patient a trip to the pharmacy. A one-time dose of Phenergan is not going to relieve persistent nausea and vomiting. The patient would need multiple doses in order to complete her round of antibiotics. Besides, you said, " Hospital in and of themselves don't dictate how I treat my patient anyway, that's my Medical Director's job. " Mike It has been a pleasure debating with you Mike. Feel free to continue this exchange. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 Text color doesn't come through......comments inline > You're right, you cannot generalize all calls into one category or the > other, which is why you would have to have protocols dictating when and how > to treat on scene but not transport. That's not necessarily in our protocols, but it is a decision reached between the patient and myself, after the treatment is rendered, and based upon what the injury and/or illness is/was. There is no pat answer, this is certainly not a black and white arena here, this is about as grey as it gets. Which is why protocols are considered guidelines to care. > There are also times when the patient doesn't require ambulance transport, > they need a cab or a bus. > > Good luck in court when the attorney for the plaintiff asks you why you told > the patient he did not need an ambulance right before he coded in the cab. > Now don't get me wrong. I see your point entirely, and I agree completely. > But, everything in medicine is about CYA. There is a lot of liability in > advising a patient that they do not need to go by ambulance. First, what type of patients are we talking about? That's the problem with the thought pattern behind those, or most of those opposed to paramedic initiated refusals. Some appear to believe that Paramedic Initiated Refusals would apply across the board. Not the case. We have all had the stubbed toes, and runny noses at 3 am, we have had people who tell you explicitly, when you arrive, that they 'don't really need an ambulance, they need a ride because their car is out of gas/broken down/has 2 flat tires " . If you like, I can send you the abstracts that show that while there are problems at this moment with PIC's, training and education is the key. Let me know, and I forward those to you. In essence, although the studies show deficiencies with PIC's, they also remark about the shortfall of training in that area. Pretty self explanatory that anyone who utilizes a skill needs training. Secondly, I do cover my a**, by doing a thorough assessment, discussing what I find with the patient, and their family if necessary, and helping them come to a sound decision. I don't talk patients who need to go by EMS, out of going. So if we expand our knowledge, which is what we all agree is the key to progression in EMS, we should be able to accept more responsibility, correct? If not, then why not? The liability issue is across the board, in our 'sue happy' society, we can file a suit for anything from failure to tell me not to do something stupid, all the way to the infamous Mc's cup of coffee. We can do everything right, have a disasterous outcome, and get sued. Do I believe that I could walk out the door right now and begin PIR's without training? No. I believe that with training, our Medics could accomplish them safely, and reduce the burden on our overtaxed systems, as well as alleviate some of the ER overcrowding. There are hospitals now that are triaging non emergent patients back OUT of the ER without treatment. Why are we afraid of the trend? If you have medics working for/with you that you just shudder to think could carry that resposibility, then they require remedial training, or they should give serious consideration to changing career fields. > > I don't think > > hospitals would be willing to take on the liability of giving us treatment > > instructions without bringing the patient in. > > Hospital in and of themselves don't dictate how I treat my patient anyway, > that's my Medical Director's job. My Medical Director has already taken on > the liability of giving me treatment instructions and guidelines which apply > with or without transporting, they're called protocols. > > > > Again, a regional issue. In our area, protocols (which you assume I am not > familiar with) are dictated by our medical director. However, our protocols > do not cover every possible patient scenario (maybe yours are more > thorough). No, actually, ours are strictly guidelines which require us to use sound decision making process, and good judgement. 15 years in the business has left me facing very few depositions, and no lawsuits. I have advised numerous patients that they did not require an ambulance to take them to the ER, some have taken my advice, others insisted on being transported, those that insisted were transported, and the majority of those were left in triage. Those, I actually beat back to the station. If a patient does not fit a particular protocol or we want to > deviate from protocol, we have to contact medical control for instructions. > In this area, the receiving hospitals make any and all decisions regarding > patient care that is not governed by protocol. If we are not transporting, > these decisions go through our county ER. When exactly does one deviate from a protocol? If your patient no longer requires the treatment listed in, say the CHF protocol, then begin treating them according to the protocol that best defines their needs, that's not deviation, that's adaptation. I have to assume that when you say 'does not fit a particular protocol', you are not referring to a patient who is not 'textbook' in their signs and symptoms. > so don't think EMS > > organizations are ready to take on the liability of determining that a > > patient does not need to be transported when it is so much safer to just > > recommend transport every time and let the patient decide. > > This is a pet peeve of mine. I'll give the latitude of saying that most > patients with SOB, or chest pain, or other issues that lend credence to them > having a serious underlying medical condtition, should be transported. There > are however, a certain percentage of the patients that we see, who are > requesting transport solely because they do not have transportation. This is > neither a medically necessary ambulance transport, nor is it judicous use of > your resources. > > > > Yes you are correct. But I don't believe the patient Mr. Grady described > falls into this category. If you want to debate over the actual percentage > of patients who go by ambulance and really, truly need an ambulance, my > experience has been this would be a small number. Which is exactly why we should embrace PIR's with caution, but embrace them none the less. Are we afraid that once all the BS calls are gone, we could no longer justify our existence? We need top expand our scope of practice. We need to be prepared to help alleviate the overuse and overcrowding. We need to become extensions of our physicians, so to speak. We won't see less activity, what we will see is activity going in another direction. > > As far as the specific situation at hand, this patient had a legitimate > > medical complaint that needed to be addressed. Since the ER had failed to > > provide a remedy for the nausea in the initial visit, it would be > impossible > > for the patient to take her antibiotics. This call should be covered by > > Medicare or other coverage. If she is not insured, don't feel bad because > > she is going to get a bill. She is the one choosing to go by ambulance; > she > > can accept the responsibility of paying her bill. Plus, you, Mr. Grady, > > made the decision to treat her at the ALS level, so you are the one > > responsible for the higher charges. > > The option was..........? Perhaps to treat her at a lower level of care? > That's absurd! Talking about opening the liability door wide open.... > > > > Mr. Grady seems to feel that this patient did not warrant ambulance > transport. If this were the case, then BLS treatment would have been > sufficient. My point was if she required the higher level of care, he > should not feel guilty about the expense. Regardless, once the patient was under your care, failure to treat him/her within your scope of practice, and to the best of your ability, would be nothing short of negligent. Do I believe she needed to be transported by EMS? I can't draw that conclusion, I wasn't there. But once you make the decision to transport, whether you feel they should or should not be transported by ambulance, becomes irrelevant. > Besides, by treating her in route to > > the hospital, you certainly justified the need for ambulance transport. > And > > since you made her feel better, you should take pride in knowing that you > > got to use the knowledge and training that you received in paramedic > school > > to fix a patient's problem. After all, isn't that why we got into this > > business. Here is one option for this particular situation. Depending on > > the time of day, the patient could have called the ER and had the > physician > > who treated her call in a prescription for Phenergan suppositories. > > > > Why couldn't the Medic attending contact the ER physician? If the physician > is willing to call in a prescription for Phengran, why couldn't the Medic > administer it while they were there? That would save the patient a trip to > the pharmacy. > > > > A one-time dose of Phenergan is not going to relieve persistent nausea and > vomiting. The patient would need multiple doses in order to complete her > round of antibiotics. Besides, you said, " Hospital in and of themselves > don't dictate how I treat my patient anyway, that's my Medical Director's > job. " > I assumed that you would have perceived it as an analogy, I apologize for the confusion. The analogy was to illustrate that if medication were necessary, and it was a medication that could be administered in the field, why then could the medic (within reason) not administer it? Apparently I need to be more explicit next time. Mike Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 > > Steve, > > Your position is actually supported by at least one major study that showed > a disappointingly low correlation between paramedic estimations of who would > be admitted to the hospital and who actually was. Those same studies though, also illustrate that the most significant reason, is lack of training. As with any skill, training is mandatory.... > > The big differences come with medical patients who have conditions that we > don't study and where lab tests are a big part of the diagnostic process. > That is why I am so adamantly against service initiated refusals except in those > cases like a mashed finger or stubbed toe that obviously don't need ambulance > transportation. > > I NEVER no-ride a patient with any sort of even semi-significant medical > complaints. I agree wholeheartedly. Mike Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 A return visit within 72 hours is an automatic risk management flag in any ED. It is incumbent upon the ED physician to assure that nothing was missed. Also, he or she should have a very low threshold for admitting the patient for an additional work-up. In many EDs, a third visit mandates admission for all but the most minor of problems. Better to admit than discharge and miss something. A kidney infection in an older person (or in a younger person for that matter) is pyelonephritis and can result in renal failure and generalized sepsis. This differs from the bladder infections you see in females of reproductive age. You can try an injection for a thrid generation cephalosporin and gentamycin. But, if the patient cannot keep PO meds down they should be admitted. Sounds like this patent needed admission for anti-emetics, pain control, and at least a day or two of parenteral antibiotics (at least until the urine and blood cultures are back). BEB E. Bledsoe, DO, FACEP Midlothian, TX Why go to the ER? We are called to the home of an 80 year old patient who was seen earlier today in an ED for fever, chills, nausea, vomiting, flank pain, and undiffierentiated pain in many other areas. This patient has had stints placed 3 years ago, takes meds for arthritis, hypertension, osteoporosis, anxiety, depression, and anticoagulants. She was diagnosed in the ED with a kidney infection and discharged with a prescription for Levaquin, nothing for nausea, and no followup instructions. She had taken her Levaquin as prescribed and vomited it up. She had vomited to the point that she was experiencing severe abdominal pain, and she was weak and really distressed from the nausea. She was hurting. She felt like she was going to faint at any moment. Her vitals were OK but she was in obvious distress from the nausea. Her daughter was adamant that we take her back to the hospital from whence she had come earlier today. Now, what were we to do for this patient? There was nothing to do but to transport her back to the ED from whence she came, give some promethazine for the nausea enroute, and deliver her back to the ER. After administration of the Phenergan, she got better and the nausea stopped. I'm sure that she was once again released almost immediately and almost beat us home. If there was an intelligent system of alternative care we would not have transported her back to the ER at all. We would have given the Phenergan, left instructions to call us if things got worse, talked it all over with a medical director physician who was available to us by cellular, and spared our patient the expense of an ambulance transport that cost her more than $600.00. Again and again, we are called to transport medical patients to one of the ERs that we feed into, and again and again the patients beat us home. Again and again, we are called to take them to the ER a few hours after they were discharged from the ER that we took them to a few hours before, and they are sicker than they were before. Invariably we find that the treatment that they received in the ED was inadequate, and if they had received the right care in the first place we wouldn't be taking them back. The cost of these re-transports when considered as something that happens all over the country every day, many times a day, is immense. The cost must be absorbed by the EMS service that does these unneeded transports, and it also falls on the hospital who once again have to deal with patients that ought not have come back to them. Why have we not developed a system that allows EMTs and Paramedics to take care of the needs of patients in the field and avoid placing patients who don't need to be seen in the hospital in the ER? Do any of the rest of you experience frustration with the services and treatment that your patients receive in the ERs that you transport to? Please post your experiences. And if you have experiences that are really positive, please also post those. I want to know if there are ERs that I would want to go to. Mr. Grady Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 14, 2004 Report Share Posted June 14, 2004 A return visit within 72 hours is an automatic risk management flag in any ED. It is incumbent upon the ED physician to assure that nothing was missed. Also, he or she should have a very low threshold for admitting the patient for an additional work-up. In many EDs, a third visit mandates admission for all but the most minor of problems. Better to admit than discharge and miss something. A kidney infection in an older person (or in a younger person for that matter) is pyelonephritis and can result in renal failure and generalized sepsis. This differs from the bladder infections you see in females of reproductive age. You can try an injection for a thrid generation cephalosporin and gentamycin. But, if the patient cannot keep PO meds down they should be admitted. Sounds like this patent needed admission for anti-emetics, pain control, and at least a day or two of parenteral antibiotics (at least until the urine and blood cultures are back). BEB E. Bledsoe, DO, FACEP Midlothian, TX Why go to the ER? We are called to the home of an 80 year old patient who was seen earlier today in an ED for fever, chills, nausea, vomiting, flank pain, and undiffierentiated pain in many other areas. This patient has had stints placed 3 years ago, takes meds for arthritis, hypertension, osteoporosis, anxiety, depression, and anticoagulants. She was diagnosed in the ED with a kidney infection and discharged with a prescription for Levaquin, nothing for nausea, and no followup instructions. She had taken her Levaquin as prescribed and vomited it up. She had vomited to the point that she was experiencing severe abdominal pain, and she was weak and really distressed from the nausea. She was hurting. She felt like she was going to faint at any moment. Her vitals were OK but she was in obvious distress from the nausea. Her daughter was adamant that we take her back to the hospital from whence she had come earlier today. Now, what were we to do for this patient? There was nothing to do but to transport her back to the ED from whence she came, give some promethazine for the nausea enroute, and deliver her back to the ER. After administration of the Phenergan, she got better and the nausea stopped. I'm sure that she was once again released almost immediately and almost beat us home. If there was an intelligent system of alternative care we would not have transported her back to the ER at all. We would have given the Phenergan, left instructions to call us if things got worse, talked it all over with a medical director physician who was available to us by cellular, and spared our patient the expense of an ambulance transport that cost her more than $600.00. Again and again, we are called to transport medical patients to one of the ERs that we feed into, and again and again the patients beat us home. Again and again, we are called to take them to the ER a few hours after they were discharged from the ER that we took them to a few hours before, and they are sicker than they were before. Invariably we find that the treatment that they received in the ED was inadequate, and if they had received the right care in the first place we wouldn't be taking them back. The cost of these re-transports when considered as something that happens all over the country every day, many times a day, is immense. The cost must be absorbed by the EMS service that does these unneeded transports, and it also falls on the hospital who once again have to deal with patients that ought not have come back to them. Why have we not developed a system that allows EMTs and Paramedics to take care of the needs of patients in the field and avoid placing patients who don't need to be seen in the hospital in the ER? Do any of the rest of you experience frustration with the services and treatment that your patients receive in the ERs that you transport to? Please post your experiences. And if you have experiences that are really positive, please also post those. I want to know if there are ERs that I would want to go to. Mr. Grady Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 15, 2004 Report Share Posted June 15, 2004 My how history repeats itself. Wasn't this a topic of discussion at the 1993, 94, 95 EMS conferences in Fort Worth where the head of MedStar was touting his plan for an " advanced paramedic " that could be summoned by the 9-1-1 unit to do detailed patient assessment with some limited lab capabilities and then work out a treatment plan or schedule an office visit with the patient's family. I thought they had even gotten a bus to convert into a type of rolling clinic for this project. The goal was to reduce non-emergency ER visits and increase utilization of clinic/doctor's office for calls that weren't emergency and could wait until office hours. He was basing this somewhat on the protocols used by frontier medics/providers in Alaska, off-shore medics and other countries where the village EMT-P was the only health care provider available. What ever happened to this project? Barry Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 15, 2004 Report Share Posted June 15, 2004 Does the name Stout ring a bell? If it does, then you can probably answer your own question. He forgot that when he achieved this goal, if he ever did, there would be no transport charge. Whoops. How is his private ambulance going to make any money? Andy Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 15, 2004 Report Share Posted June 15, 2004 From: rachfoote@... > there would be no transport charge. Whoops. How is his private ambulance > going to make any money? > Sas to say, but that appears to be a major stumbling block, many (not all) of those opposed to PIR's are working for the private industry. Mike Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 15, 2004 Report Share Posted June 15, 2004 In a message dated 6/15/2004 7:40:59 PM Central Standard Time, silsbeeems@... writes: First I really don't want to sound stupid, but if Dr.'s still made house calls half you job would be unnecessary. If people paid medical bills Dr.'s would still make house calls. Your primary job it to transport the sick and injured while making them comfortable and intervening in there need for medical care and stabilizing them when possible. Transporting people is your job why are you looking for an excuse to not transport. If you don't want to transport and only give medical care go to work in a hospital. , I think you have missed the point of Mr. Grady's original post. If there were ways that we could take the pressure off of the hospital emergency room by treating minor discomfort and wounds, it would be a plus. I am in the business of treating AND transporting, not just transporting. We would have no protocols to follow if all we did was transport. Our profession came out of the need to have people treated by physicians prior to coming to the ER. We are those physicians. We work under his/her license and there are many occasions that we could prevent hospital overload if allowed to treat and release at home. Andy Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 15, 2004 Report Share Posted June 15, 2004 First I really don't want to sound stupid, but if Dr.'s still made house calls half you job would be unnessacery. If people paid medical bills Dr.'s would still make house calls. Your primary job it to transport the sick and injured while making them comfortable and intervening in there need for medical care and stabilizing them when possible. Transporting people is your job why are you looking for an excuse to not transport. If you don't want to transport and only give medical care go to work in a hospital. Why go to the ER? We are called to the home of an 80 year old patient who was seen earlier today in an ED for fever, chills, nausea, vomiting, flank pain, and undiffierentiated pain in many other areas. This patient has had stints placed 3 years ago, takes meds for arthritis, hypertension, osteoporosis, anxiety, depression, and anticoagulants. She was diagnosed in the ED with a kidney infection and discharged with a prescription for Levaquin, nothing for nausea, and no followup instructions. She had taken her Levaquin as prescribed and vomited it up. She had vomited to the point that she was experiencing severe abdominal pain, and she was weak and really distressed from the nausea. She was hurting. She felt like she was going to faint at any moment. Her vitals were OK but she was in obvious distress from the nausea. Her daughter was adamant that we take her back to the hospital from whence she had come earlier today. Now, what were we to do for this patient? There was nothing to do but to transport her back to the ED from whence she came, give some promethazine for the nausea enroute, and deliver her back to the ER. After administration of the Phenergan, she got better and the nausea stopped. I'm sure that she was once again released almost immediately and almost beat us home. If there was an intelligent system of alternative care we would not have transported her back to the ER at all. We would have given the Phenergan, left instructions to call us if things got worse, talked it all over with a medical director physician who was available to us by cellular, and spared our patient the expense of an ambulance transport that cost her more than $600.00. Again and again, we are called to transport medical patients to one of the ERs that we feed into, and again and again the patients beat us home. Again and again, we are called to take them to the ER a few hours after they were discharged from the ER that we took them to a few hours before, and they are sicker than they were before. Invariably we find that the treatment that they received in the ED was inadequate, and if they had received the right care in the first place we wouldn't be taking them back. The cost of these re-transports when considered as something that happens all over the country every day, many times a day, is immense. The cost must be absorbed by the EMS service that does these unneeded transports, and it also falls on the hospital who once again have to deal with patients that ought not have come back to them. Why have we not developed a system that allows EMTs and Paramedics to take care of the needs of patients in the field and avoid placing patients who don't need to be seen in the hospital in the ER? Do any of the rest of you experience frustration with the services and treatment that your patients receive in the ERs that you transport to? Please post your experiences. And if you have experiences that are really positive, please also post those. I want to know if there are ERs that I would want to go to. Mr. Grady Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 15, 2004 Report Share Posted June 15, 2004 Update on the patient in the scenario. She responded well to the Phenergan that was given by EMS. At the hospital she waited about 5 hours to be seen by a physician, who was a different physician from the one who had seen her before. Since she wasn't vomiting then he didn't want to give her anything for nausea, but after her daughter put up a battle, a prescription was finally written and she once again came home. The next day (Monday) she was able to get hold of her private physician who scheduled her for some additional tests, and will see her tomorrow. She has kept her Levaquin down (only has to do it once a day) and is feeling better. She was doing well today and singing the praises of EMS. However, she still complains of flank pain and general weakness. Thanks to all who contributed to this colloquy. Mr. Grady Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 15, 2004 Report Share Posted June 15, 2004 Update on the patient in the scenario. She responded well to the Phenergan that was given by EMS. At the hospital she waited about 5 hours to be seen by a physician, who was a different physician from the one who had seen her before. Since she wasn't vomiting then he didn't want to give her anything for nausea, but after her daughter put up a battle, a prescription was finally written and she once again came home. The next day (Monday) she was able to get hold of her private physician who scheduled her for some additional tests, and will see her tomorrow. She has kept her Levaquin down (only has to do it once a day) and is feeling better. She was doing well today and singing the praises of EMS. However, she still complains of flank pain and general weakness. Thanks to all who contributed to this colloquy. Mr. Grady Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 15, 2004 Report Share Posted June 15, 2004 Update on the patient in the scenario. She responded well to the Phenergan that was given by EMS. At the hospital she waited about 5 hours to be seen by a physician, who was a different physician from the one who had seen her before. Since she wasn't vomiting then he didn't want to give her anything for nausea, but after her daughter put up a battle, a prescription was finally written and she once again came home. The next day (Monday) she was able to get hold of her private physician who scheduled her for some additional tests, and will see her tomorrow. She has kept her Levaquin down (only has to do it once a day) and is feeling better. She was doing well today and singing the praises of EMS. However, she still complains of flank pain and general weakness. Thanks to all who contributed to this colloquy. Mr. Grady Quote Link to comment Share on other sites More sharing options...
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