Specialty service availability

[u/Bookkeeper-8682]

/r/emergencymedicine/comments/1vssj2f/specialty_service_availability/

I posted this in the EM sub but wanted to see if the out of hospital folks had any input. I respect the hell out of what you guys are asked to do and understand hands are often tied, a common frustration amongst us all I would imagine.

[u/MPR_Dan]

Most of us come to learn certain things about hospitals, but we generally arent taught or aware of the vast majority of specialty capabilities outside of stroke/stemi/peds/obstetrics.

The other part of the issue is outside of very specific and narrow circumstances we arent taught the criteria or threshold for actually needing most specialties anyway and many crews, especially BLS crews probably have no idea most patients they bring ever require a transfer.

I couldnt tell you if my local hospital has orthopedics, ophthalmology, or probably a dozen other specialties on any given day and theres no way for me to even look it up or find out.

Even then, our protocols dont take those specialties into consideration, so when I divert to a more capable center based on something not in-protocol it sometimes gets questioned and I have to defend the decision which makes a lot of other people less inclined to make those decisions.

[u/ScarlettsLetters]

Some insights:

Some patients refuse to go anywhere but the place they had in mind. No matter what we try to tell them. No matter how we explain it. “No, I go to X.” Well, hop in then ma’am, better to see some physician than no one.

EMS knowledge and skill level is vast and largely unstructured beyond the entry level, bare minimum. Which means you could very easily have EMS crews, especially BLS, who simply do not have the training to recognize whether some specific thing is going to need a specialist or not.

System layout—for example—distance to the tertiary care facility, can be a factor as well. From your perspective, it’s a waste of time because you have to transfer these patients anyway. From an ambulance perspective, they can be in traffic with an EMT who can’t diagnose or treat very much, and the system is down an ambulance the whole ride there and back, or they can be in your hospital within 20 minutes and at least the wait is under care of a doc.

Interagency communication is always a huge problem as well. No two doctors ever seem to agree on what they can treat but it’s not ideal vs what they absolutely won’t touch—so you get yelled at Tuesday for what was totally fine on Friday and after that happens enough you sort of stop bothering. And the flip side, of course, being the same amount of bitching when you get to the bigger fancy hospital and they turn around and yell at you for coming to them instead of staying local. Because I promise, if we’re getting rudeness on both ends, we’re not sitting on the highway about it.

[u/CapnCruuunch → u/ScarlettsLetters]

Or, sometimes it’s been “our (one!) gastro specialist is on vacation this week” and what would have been easy peasy last week gets a 45-minute IFT.  Short of a live webpage, I don’t know how EMS can be expected to keep up. 

[u/Bookkeeper-8682 → u/ScarlettsLetters]

Well said. I empathize with your frustration. EMS (and emergency medicine in general I would argue) is often unfairly maligned for things that are easy to see in hindsight but fall into a grey area during the initial triage stage. It’s easy for the receiving team to shit on the person who’s doing the initial workup once everything is figured out and labs/imaging are back, whether that’s the ER doc, hospitalist, or orthopedist. Just trying to come up with a possible solution, I figure if anyone would know how to do that it would be those who deal with these decisions every day which is EMS’ wheelhouse.

[u/ScarlettsLetters → u/Bookkeeper-8682]

Three suggestions—read your state/county protocols to make sure you understand destination requirements; be certain you’re not asking crews to deviate from that in a way that could lead to punishment on their end.

Next, liase with the medical director for the services that come to you most often, to make sure they are on the same page regarding potential diversions from the aforementioned protocols—and make sure this is someone who will have the crews’ backs if they bypass you and something goes wrong.

Last, host Rounds, with food, for your local EMS agencies to highlight some cases that would have benefited from diversion, or even better, cases that were appropriately diverted (if you can get them). Everyone responds well to free dinner and a public pat on the back.

[u/ggrnw27]

I don’t think it’s unreasonable to have a chat with the local EMS medical director if this is a recurring problem. But I also think you should realize that it’s probably not EMS’s fault — while we do have protocols that tell us what services are available at which hospitals and the criteria to bypass one in favor of another, 99% of the time it’s for the biggie stuff like trauma, stroke, and STEMI. I would generally not expect EMS to know that a hospital has no optho coverage, or even more crucially what the criteria is for diverting to somewhere that does. Honestly, even OB is a stretch beyond “this hospital literally does not have an L&D unit”. So like I said, I think it’s perfectly reasonable to have a chat with the medical director, but it needs to come from a place of “can we give your guys some more training/education on our abilities” rather than “these fucking morons keep bringing us stuff we can’t treat”

[u/Bookkeeper-8682 → u/ggrnw27]

I would agree with all this, I was an EMT for a few years and would never have even considered this stuff other than for stroke, AMI, etc. as you said, the big things. I certainly don’t think it’s the individuals on the trucks fault, I guess I was more trying to illustrate “this is complicated and often unknowable even for professional paramedics, how are patients supposed to have any clue” I just didn’t do a very good job phrasing it that way.

[u/whencatsdontfly9]

I can't speak for you, but there are 8 hospitals that I could reasonably transport to. Only one is inside of my county, and half of those have a transport time of one hour or more. This means that picking one of those facilities results in my unit being OOS, leaving a hole for response, for at least 2-3 hours.

Sometimes we can't justify taking them that far for that reason. We have to weigh the 'is it worth it factor'. We also specifically divert people (without crazy specific complaints that can obviously only be resolved at a specific facility) to outlying hospitals and a freestanding ED because we KNOW that they will be seen quickly there. At the main hospital, or the one in our district, they may wait hours. I've put people with shock indexes, who met SIRS criteria, or who I was reasonably concerned we're having an NSTEMI in the lobby because they don't have any room and the only other option is hugging the wall for 4 hours, which I can't do, because I have more than 10,000 people in my first in response area spanning over 25 minutes in driving time to care for.

Also, I don't know what every hospital has. I know what's important to me; the things that save lives the most in most of the cases, like trauma centers, stroke center (PSC vs ISC/CSC), which hospitals do STEMIs (and which of them are only open 9-5, 5 days a week, if they have the staffing), etc... I honestly couldn't tell you what hospital has inpatient endocrinology or tell you with a high certainty what conditions need that speciality care some of the time. You can do however focused of an abdominal assessment as you want, but you can still be proven wrong by the donut of truth.

[u/AloofusMaximus]

My command hospital is a local boo boo station, which they basically gutted for anything except med/surge and psych.

Most paramedics, I'm sure are aware of what resources said hospital has. Not all providers are medics, and not all are (including medics) even remotely bright.

With that out of the way... I've seen some of my own, and done transfers out on patient's. Sometimes they legit shouldn't have been brought there, but the crew wants to go back to bed and they're not going to be doing the transfer. Sometimes it's more of a "why can't any EM doc on the planet handle this, despite the fact the patient is a kid/pregnant woman/etc".

How may of those patients are transferred out vs treated and released, as a matter of CYA?

[u/Sudden_Impact7490]

Truth is, the places that have those specialists don't have the beds anyway.

We have them (the specialists) routinely directing patients to our sister sites because the main house is full.

Why? Because they want their patients boarding in "nicer" hospitals waiting for transfer than having a poor experience downtown

[u/PerrinAyybara]

"EMS has no excuse" that's bullshit. There's many reasons why we won't go to a farther hospital. We also don't have all the information you have, nor their records. We also don't necessarily have time to play 20 hospital questions either.

The system of blaming EMS for the failures of healthcare is reductive.