So you’ve gotten the 911 call right? You’ve taken care of the patient on scene, done all those fancy skills that you learned in the schoolhouse, and now for the next step…. where do we go?
Well, we have so many choices to choose from. In scenario 1, we have a patient who has a Cincinnati positive stroke assessment with a LAMS score of 1-1-2 (3) We have that local, tertiary hospital that’s only 10 minutes away. We’ve got a thrombectomy capable neuro center that’s 24 minutes away and a an intermediate hospital capable, primary stroke center that’s 16 minutes away. Which do you choose?
In another scenario, we have a patient who presents with what you believe is septic shock, the local hospital you know from running all day has no available ICU beds but is only 7 minutes away, the next closest hospital is 30 minutes away, but you are ALS capable and can handle keeping the patient stable for the duration of transport, which facility do you transport to?
What I am trying to address here is critical decision making when on 911 calls. Not every call should just be “load and go to the closest facility” in fact, many protocols state closest appropriate facility. In my own state, there is an agreement signed between the state EMS agency and the hospitals to allow the hospitals to go on “color” statuses (some other states identify this as “diversion” and “reroutes”) For simplicity sake, we’re going to stick with the 2 primary colors we deal with… Yellow and Red. Yellow generally implies that the Emergency Room is overloaded with patients. This includes EMS units already there and en route (yes, they track that too!) and their waiting room from walk-ins. Red status implies that there are NO cardiac monitored beds available throughout the entire hospital. This doesn’t mean just the ER…. It’s the entire facility. (Note, it’s not just physical beds, they may lack the proper staff to care for patients in those beds too)
Why do I bring those up? Because those absolutely should be brought into your decision making processes. So you have a stable patient, who potentially will be admitted, but you know that the closest hospital is on “colors” (or your state/local’s equivalent) so there will be a significant delay. The patient will likely sit in the ER for hours, and I do mean HOURS waiting for either a bed “upstairs” to open or for a bed elsewhere to open up and then they have to wait for an interfacility transport (IFT to come get them. From my time prior to career 911, and my time as a patient before, that wait for IFT can be 3-6 hours or more…. Sure, you may have gotten back to your recliner sooner, or cleared for that next stubbed toe faster, but did you really serve the patient?
Think about the patient the next time when you’re delivering care. Think about the needs beyond the call. Think about the outcomes. A friend of mine once suggested, and I concur that every medic student would do well to have a shift shadowing a hospitalist to see outcomes and how the “backend” of our EMS calls are handled. Too often I see EMS crews only worried about the immediate needs, which yes, they are important, but we should be thinking about the end goals of the patients as well. This is what will separate us as technicians into clinicians. It is often difficult to recognize these situations, and when a patient would best benefit from these decisions. Often times we can only learn when best to apply this through advanced knowledge and experience gained through time and education.
Separate note: This can be protocol and state/locale specific. You may not be able to just make that call on your own. You as a clinician may have to consult online medical direction and request the ability to bypass a local ER for your patient. If you have to make that call, be prepared to answer the hard question of WHY do you believe that the patient would be better served at a different facility. Be ready to use sound medical reasoning, not just your “feelings” on a radio report. I always recommend erring on the side of your patient, so do so with your best medical knowledge and with consult accordingly.
/End Rant
-The Hazmat Medic
