Turf Games

     EMS Reruns is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. But it offers you a luxury you don't have on scene: plenty of time to think. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we'll pay you $50. We don't know everything, but we do know a lot of smart people. If we need to, we'll contact just the right experts and share their advice with you. E-mail ideas to Nancy.Perry@cygnusb2b.com.

     A big-county medical center in the area where I recently worked had a problem because a lot of medically insured patients were bypassing them for a smaller facility about 10 minutes down the road. The latter facility was nicer, with tastier food, a smaller ED, fewer "undesirables," better decorations and more private rooms. The county's strategy was to open a third, smaller, very limited-service satellite hospital in one of our area's more affluent towns.

     The patients' rooms at the newest hospital are appointed like Las Vegas hotel suites. Unfortunately, several departments aren't actually open. Consequently, a large number of incoming patients are being transferred five miles back to the big medical center after all-on some days, all of them.

     Our local policy is to take stable patients wherever they want to go. The new facility's opening was well advertised, so the public is familiar with it.

     If the requested receiving facility has been full all day and transferring all of its patients (at $600 a pop or more), shouldn't our paramedics let their patients know that in advance?

     The answer to that question should vary on a case-by-case basis. Sometimes a patient needs to be in an ED and not a moving ambulance, regardless of its destination. But if that's not the case, I don't think you go wrong by looking out for the public. How you do that depends on how much online medical control you have in your system. If those kinds of decisions are supposed to be guided by a doc, play by the rules and involve a doc. You can ask questions later.

     The local fire department occasionally rides with the transport service, but they don't want their firefighters to leave the city. They want patients to go to the new facility, which is in their district, because they're trying to build support for their own transport service. They don't seem to get that part about the transfers. How can the transporting paramedics win under those circumstances?

     Based on the information provided, this situation is a setup that may eventually ruin some paramedics' careers. It needs to be settled between chief executives, not caregivers. Certainly, EMS is not about what we want, but what people need. (Curiously, you said you used to work in this system.)

     EMS is in a position to help the facilities we deal with by making sure patients arrive at appropriate destinations the first time. We didn't always get a chance to do that. In the case of head injuries, for example, only two of 13 hospitals in our area had facilities to care for them. If we transported them to a primary ED, they got a tetanus shot, some Demerol and a two- to four-hour wait while transfer arrangements were made between facilities. Why not take them where they need to go in the first place? That would have eliminated unnecessary workload at the discharging facility, and it would have spared patients' families a lot of added cost.

     Can't argue with you. In the absence of a specific protocol to the contrary, it usually makes sense to transport someone a few extra minutes for the right kind of care. The trauma, stroke and cardiac alert systems are all designed to work that way. Whether a patient has a few minutes or not would really be the crew's call. If there is a protocol and it doesn't seem to fit a given situation, maybe you could put that ride-along medic to work while you involve a doc in the decision.

     What about informed consent? If you know a receiving facility can't handle a patient (based on condition) and you don't involve the patient in the decision, are you giving the patient the ability to make an informed decision about where he receives care?

     Patients are customers. If we have time to explain things, they deserve to know what we know. Unfortunately, lots of them can't make good decisions. In those cases, I think they generally trust us to argue, decide and act in their behalf.

     I think we're accountable for doing exactly that.

Idea submitted by Chad Stephen Albert.

Thom Dick has been involved in EMS for 37 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS Magazine's editorial advisory board. Reach him at boxcar_414@yahoo.com.

Thom Dick is a featured speaker at EMS EXPO, October 11-13, in Orlando, FL. For more information, visit www.emsexpo2007.com.