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

The post Making the Right Patient Destination Decision…thinking ahead first appeared on The Hazmat Medic.

Recently, I saw a series of videos, vblogs or whatever the younger crowd is calling them these days about DNRs, and end of life care being discussed, and the resulting commentary was frankly disturbing. This lead to a discussion with some trusted colleagues (fellow medics) as well as a family member of my own who is a BSN and RN. One of the scariest things I’ve found, in general, is that many many people treat DNRs as “do not treats” regardless of the “level” of DNRs. An example in my state, is there are DNR B (Palliative only) vs DNR A/DNIs, which is “do everything except intubate” and they still don’t try as hard. Without delving deep into the multitude of studies, they do exist showing that even in facilities, staffs don’t try as hard regardless of “types” of DNRs when they exist. I bring all this up as a preamble to the core of these underserved patient populations.

Arguably, you’d think the job of explaining the DNR/MOLST/POLST form (depending on your state) would fall on the hospitalist and/or hospice group right? Except often times they’re all too busy to do so. Often times just what is on the DNR form isn’t actually explained to a patient. How often do you see the front page checked “palliative only” yet the back page (the one for the inpatient stuff) shows “do everything.” I had a patient once where no one explained the difference to them at what DNR A1, DNR A2 (DNI) and DNR B meant. They literally had no idea what they were signing, nothing was explained to them. On the other hand, when they are sent home on hospice care often times they just get dropped off by a private EMS transport and left… with little to know information or even planning or care in how to help arrange their homes to help prevent future calls.

Often times, family members call us because they don’t know what to do. We are their last line of defense, the solution to the “hand in the air, I’m lost.” An abbreviated example, I was called for a service call to a residence to assist a family member with her recently returned to home husband who had been placed into hospice care. The IFT crew had just brought him home and left him in his upstairs bedroom. They’d provided no guidance on helping her prepare the home for him, or how to setup the house for his end of life care. The hospice team had not gone over any of the papers with her, none of the MOLST forms, DNR forms, living wills, etc. Now being on the fire engine, we don’t carry stair chairs (she had asked us to help move him downstairs) so we had called for an ambulance to bring one to us non-emergency, while we waited I decided to go over some of this stuff with her. Spent the next 20 minutes or so helping her rearrange some furniture, plan how to setup her home, go over the MOLST form, what numbers in the folder to contact regarding the living will etc. Explaining what to call for, what we need we can help her with, what we can’t actually help her and everything else. In the end, the extra 20 minutes spent with the patient’s spouse set her mind at ease, has definitely alleviated further calls for service that many would call “useless” or “wasteful” and improved the quality of life for the patient in his end-of-life care for comfort in the end of life care.

The bottom line here, is that while less than maybe 5-10% of the calls are “guts and glory” we should be pay attention to the other 90-95% of the calls. Take the extra few minutes, even if you’re tired and don’t want to, to just speak for a few minutes to the family members. Those few minutes might save you an hour or two later. That public perception makes a big difference later.

The post The Underserved community within our community. first appeared on The Hazmat Medic.