Time for Intelligence in Implementing EMS

During the recent snowstorm, the governor of New Jersey declared a state of Emergency closing all roads to nonemergency vehicles.  As luck would have it, I was on shift at one of the hospitals where I work.  My colleague received a call from a local EMS squad.   A stabbing was inbound.   The EMT on the phone relayed no valuable details except she didn’t care how bad the wounds were. While she hadn’t even arrived at the scene yet, with the weather being bad as it was, she was coming to us  “no matter what”.   The hospital where I worked that day is a small community hospital without in house surgery, no trauma team, and a physician staff for the entire hospital that evening which probably consisted of two ER physicians, an anesthesiologist, and two hospitalists.   Several miles down the road is a larger hospital with significantly more resources.   While the above vignette alone can generate significant discussion, this is only one item in my ire over local prehospital care

The literature is full of studies how the Europeans will actually divert ambulances with acute MI patients from local hospitals to those with catheterization labs.  Two Emergency Physicians whom I enjoy listening to on their Emergency Medicine literature review CDs, Doctors Jerry Hoffman and Richard Buckata, not long ago discussed how patients having acute coronary events in the driveways of European hospitals would be told not to unload their patients, travel to the next facility with the appropriate interventional resources, and how much better the outcomes are for these patients.   This is certainly not the practice in the region where I work.

Where is the logic of a pediatrician sharing in clear language her high clinical suspicion for acute appendicitis in a child with an EMS team and then those same EMTs making the decision to bring that child to a hospital without pediatrics or pediatric surgery?  This defies any logic.  What is accomplished?  Delay in definitive care, added unnecessary expensive, additional transport time, and psychological trauma to the child and her family.

At another hospital where I also work, local EMS squads historically will ignore bypass requests.  Responses by EMTs to questions regarding their rational for ignoring critical care divert and bypass requests as the nurses share with me that they have run out of pumps and cardiac monitors, “The patient insists on coming here”.  Other responses I have received from these same EMTS and medics as they bypassed two and three hospitals (incidentally, all within the same hospital system with the same physician groups) on their 25 mile trek to this particular hospital are “ divert is a courtesy request only,” and, this is my personal favorite,  “ we don’t want to be accused of kidnapping patients”.   Kidnapping patients? ! I understand completely that while on divert a hospital cannot expect all EMS inflow to stop and critical care patients will still arrive. Bypassing multiple hospitals that aren’t overwhelmed due to a family request is endangering ALL patients in that ER – including the one being “Kidnapped!” When someone is calling 911, they are calling for a rescue service and not a taxi ride.  Of course, I should share that this problem has been partially “solved.”  Many hospital administrators regionally are refusing to allow the ED Attending physicians to warn EMS squads of strained resources by forbidding bypass requests.

I have been in the streets myself for many years working for EMS systems.  I helped pay my way through school working in Brooklyn and Queens. I am very proud of my background with New York City EMS.  I am currently actively involved in EMS education.  Hence, I don’t believe anyone can say I do not know what I am talking about in regards to “being in the field.”    Under most circumstances, when I worked in New York, you were taken to the closest hospital.  No “special trips” taking a rescue unit out of it’s assigned region because the family likes the décor at a different hospital better.  It was simple.  Burns?  Burn unit.   Trauma?   The nearest trauma hospital. If the local hospital in our “PAR” was over whelmed, we tried to “share the burden” with the next closest facility

Going back to that snowstorm shift and the trauma patient, the blade missed the femoral artery on CT angiography.   The child who had been taken past a facility with pediatrics by local EMS had no difficulties in being transferred to another pediatric surgical hospital by ground three hours later after I had back all the studies to make a convincing argument to the surgeon at this other hospital to accept transfer. CT confirmed acute appendicitis.  As far as the local roads were concerned that night, while I am sure some portions of New Jersey were hit hard, I enjoyed listening to Jimmy Buffett on the radio as I took my time driving the some odd twenty-five miles home in my car without any difficulties.

6 Comments

  • Many EMS systems (not pre-hospital IMHO) neglect to establish relationships with regional resources including ERs, specialty care and the like. I came from a system that limited information going to crews in the field in an effort to increase transports through the door.
    Luckily, here in San Francisco, we have a remarkably detailed diversion and specialty care receiving facility policy. Divert is considered an order from the receiving MD unless they are a specialty care center for that patient’s condition.
    Micro surgery without trauma has a particular destination, Peds centers are clearly advertised and each update to policy includes changes in STEMI, scanner status etc.
    And I know we’re the lucky ones.
    EMS education doesn’t spend much time on specialty care receiving facilities I think because so many educators and administrators have no idea either. The urban legend of kidnapping patients is a liability fear ingrained on our young EMTs to make sure they don’t make too many decisions on their own, yet it has the opposite effect.
    The solution requires EMS, hospital and local EMS governing agencies to meet often to discuss changes and needs as the trend in care develop, then train their responders in the realities of transport.
    Great article.

    • I come from a similar background as you. The region I am working in currently, in regards to EMS care is a tremendous culture shock to me. I don’t know if you read my 911 article, but the Brady Emergency Care chapters regarding scene command are completely neglected where I am now. This is not simply a matter of poor education, this is lack of either retention, reinforcement, or base desire and caring.

      Thanks for the feedback! I appreciate it very much!

      Jordan

  • CBEMT says:

    Every time think my state’s EMS system is completely screwed (which it almost is) somebody comes in and talks about New Jersey. And then I feel better :-D

  • Skip Kirkwood says:

    This is the kind of thing that happens when medics of any sort put their personal interests ahead of those of the patient, OR where those same medics are ignorant of health care system capabilities and limitations and just assume "a hospital is a hospital."  It's why we need better EMS education, and the result of having the lowest entry-level EMS educational standards in the civilized world!

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Jordan Barnett

Jordan Barnett, MD, is an Emergency Medicine Physician in the Philadelphia Suburban Region. He has previously worked as a volunteer firefighter, was a member of New York City EMS, and provides Medical Command for several ALS Ambulance Services. Dr Barnett provides EMS consultation services. Additionally, he is actively involved with EMS education.

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