Emergency services - Stroke Victims Are Often Taken To Wrong Hospital

Author

Stroke Victims Are Often Taken To Wrong Hospital

MrPepper11

2005-05-18, 11:40 am

A 2000 survey showed that 66% of hospitals in North Carolina lacked any
protocol for treating stroke. 82% couldn't identify patients with acute
stroke.

May 9, 2005
Stroke Victims Are Often Taken To Wrong Hospital
Outdated Ambulance Rules, Inadequate ERs Make Dangerous Ailment Worse
Lessons From Trauma Centers
By THOMAS M. BURTON
Staff Reporter of THE WALL STREET JOURNAL

Christina Mei suffered a stroke just before noon on Sept. 2, 2001.
Within eight minutes, an ambulance arrived. Her medical fate may have
been sealed by where the ambulance took her.

Ms. Mei's stroke, caused by a clot blocking blood flow to her brain,
occurred while she was driving with her family south of San Francisco.
Her car swerved, but she was able to pull over before slumping at the
wheel. Paramedics saw the classic signs of a stroke: The 45-year-old
driver couldn't speak or move the right side of her body.

Had Ms. Mei's stroke occurred a few miles to the south, she probably
would have been taken to Stanford university Medical Center, one of the
world's top stroke hospitals. There, a neurologist almost certainly
would have seen her quickly and administered an intravenous drug to
dissolve the clot. Stanford was 17 miles away, across a county line.

But paramedics, following county ambulance rules that stress proximity,
took her 13 miles north, to Kaiser Permanente's South San Francisco
Medical Center. There, despite her sudden inability to talk or walk and
her facial droop, an emergency-room doctor concluded she was suffering
from depression and stress. It was six hours before a neurologist saw
her, and she never got the intravenous clot-dissolving drug.

In a legal action brought against Kaiser on Ms. Mei's behalf, an
arbitrator found that her care had been negligent, and in some aspects
"incomprehensible." Today, Ms. Mei can't dress herself and walks
unsteadily, says her lawyer, Richard C. Bennett. The fingers on her
right hand are curled closed, and she has had to give up her main
avocations: calligraphy, ceramics and other types of art. Kaiser
declined to comment beyond saying that it settled the case under
confidential terms "based on some concerns raised in the litigation."

Stroke is the nation's No. 1 cause of disability and No. 3 cause of
death, killing 164,000 people a year. But far too many stroke victims,
like Ms. Mei, get inadequate care thanks to deficient medical training
and outdated ambulance rules that don't send patients to the best
stroke hospitals.

Over the past decade, American medicine has learned how to save stroke
patients' lives and keep them out of nursing homes. New techniques
offer a better chance of complete recovery by dissolving blood clots
and treating even more lethal strokes caused by burst blood vessels in
the brain. But few patients receive this kind of treatment because most
hospitals lack specialized staff and knowledge, stroke experts say.
State and county rules generally require paramedics to take stroke
patients to the nearest emergency room, regardless of that hospital's
level of expertise with stroke.

Stroke care is positioned roughly where trauma care was a
quarter-century ago. By 1975, surgeons expert at treating victims of
car crashes and other major accidents realized that taking severely
injured patients to the nearest emergency room could mean death. So the
surgeons led a push to make selected regional hospitals into
specialized trauma centers and to overhaul ambulance protocols so that
paramedics would speed the most severely injured to those centers. Now,
in many areas of the U.S., accident victims go quickly to a trauma
center, and trauma specialists say this change has saved lives and
lessened disability.

Eighty percent or more of the 700,000 strokes that Americans suffer
annually are "ischemic," meaning they are caused by blockage of an
artery feeding the brain, usually a blood clot. Most of the rest are
"hemorrhagic" strokes, resulting from burst blood vessels in or near
the brain. Although they have different causes, both result in brain
tissue dying by the minute.

Several factors have combined to prevent improvement in stroke care. In
some areas, hospitals have resisted movement toward a system of
specialized stroke centers because nondesignated institutions could
lose business, according to neurologists who favor the changes. In
addition, stroke treatment has lacked an organized lobby to galvanize
popular and political interest in the ailment.

Doctor Ignorance

A big reason for the backwardness of much stroke treatment is that many
doctors know little about it. Even emergency physicians and internists
likely to see stroke victims tend to receive scant neurology training
in their internships and residencies, according to stroke specialists.

"Surprisingly, you could go through your entire internal-medicine
rotation without training in neurology, and in emergency medicine it
hasn't been emphasized," says James C. Grotta, director of the stroke
program at the university of Texas Health Science Center at Houston.

Many hospitals don't have a neurologist ready to deal with emergencies.
As a result, strokes aren't treated urgently there, even though short
delays increase chances of severe disability or death. Even if doctors
do react quickly, recent research has shown that many aren't sure what
treatment to provide.

For example, a survey published in 2000 in the journal Stroke showed
that 66% of hospitals in North Carolina lacked any protocol for
treating stroke. About 82% couldn't rapidly identify patients with
acute stroke.

As with other life-threatening conditions, stroke patients are better
off going where doctors have had a lot of practice addressing their
ailment. A seven-year analysis of surgery in New York state in the
1990s showed that patients with ruptured blood vessels in the brain
were more than twice as likely to die -- 16% versus 7% -- in hospitals
doing few such operations, compared with those doing them regularly. A
national study published last year in the Journal of Neurosurgery
showed a similar disparity.

Another major shortcoming of most stroke treatment, according to many
neurologists, is the failure to use the genetically engineered
clot-dissolving drug known as tPA. Short for tissue plasminogen
activator, tPA, which is made by Genentech Inc., has been shown to be a
powerful treatment that can lessen disability for many patients. A
study published in 2004 in The Lancet, a prominent medical journal,
showed that the chances of returning to normal are about three times
greater among patients getting tPA in the first 90 minutes after
suffering a stroke, even after accounting for tPA's potential side
effect of cerebral bleeding that can cause death. But several recent
medical-journal articles have found that nationally, only 2% to 3% of
strokes caused by clots are treated with tPA, which has no competitor
on the market.

Some authors of studies supporting the use of tPA have had consultant
or other financial relationships with Genentech. Skeptics of the drug
point to these ties and stress tPA's side-effect danger. But among
stroke neurologists, there is a strong consensus that the drug is
effective.

One reason why many patients don't receive tPA is that they arrive at
the hospital more than three hours after a stroke, the time period
during which intravenous tPA should be given. But many hospitals and
doctors don't use tPA at all, even though it has been available in the
U.S. since 1996. The dissolving agent's relatively high cost -- $2,000
or more per patient -- is a barrier. Medicare pays hospitals a flat
reimbursement of about $5,700 for stroke treatment, regardless of
whether tPA is used.

Airport Emergency

Glender Shelton of Houston had an ischemic stroke caused by a clot at
Los Angeles International Airport on Dec. 30, 2003. In full view of
other holiday travelers, Ms. Shelton, then 66, slumped over, and an
ambulance was called. It was 4:45 p.m.

By 5:55 p.m., she arrived at what now is called Centinela Freeman
Regional Medical Center, four miles away in Marina del Rey. Hospital
records show that doctors thought Ms. Shelton had suffered an "acute
stroke." But she didn't get a CT scan, a recommended initial step,
until 9 p.m. By then, she was already outside the three-hour window for
safely administering intravenous tPA. Records also say she didn't
receive the drug "due to unavailability of a neurologist until after
the patient had been outside the three-hour time window."

Ms. Shelton's daughter, Sandi Shaw, was until recently nurse-manager of
the prestigious stroke unit at the university of Texas Health Science
Center at Houston. Ms. Shaw says that at her unit, her mother would
have had a CT scan within five minutes of arriving, and tPA probably
would have been administered 30 or 35 minutes after that.

Today, according to her daughter. Ms. Shelton often can't come up with
words or relatives' names, can't take care of her finances, and can't
follow certain basic commands in neurological tests.

Kent Shoji, an emergency-room doctor at Centinela Freeman who handled
Ms. Shelton's case, says, "She was a possible candidate for tPA," but a
CT scan was required first. "The order was put in for a CT scan," Dr.
Shoji says. "I can't answer why it took so long."

A Centinela Freeman spokeswoman says, "We did not have 24/7 coverage
with our CT scan, and we had to call a technician to come in. That's
pretty common with a community hospital." The hospital has since been
acquired by a larger health system and now does have 24-hour CT
capability.

'Parochial Interests'

A hospital-accrediting group has begun designating hospitals as stroke
centers, but that is only part of what is needed, stroke experts
assert. They say hospitals typically have to come together to create
local political momentum to change state or county rules so that
ambulances actually take stroke patients to stroke centers, not the
nearest ER. New York, Maryland and Massachusetts are moving toward
creating stroke-care systems, and Florida recently passed a law
creating stroke centers. But in many places, short-term economic
interests impede change, some doctors say.

"There are still very parochial interests by hospitals and physicians
to keep patients locally even if they're not equipped to handle them,"
says neurosurgeon Robert A. Solomon of New York-Presbyterian
Hospital/Columbia. "Hospitals don't want to give up patients."

The university of California at San Diego runs one of the leading
stroke hospitals in the country. It and others in the area that are
well prepared to treat stroke patients have sought for a decade to set
up a regional system, but there has been little progress, says Patrick
D. Lyden, UCSD's chief of neurology. "Some hospitals are resisting
losing stroke business," he says. "We have the same political crap as
in most communities. Paramedics still take people to the local ER."

Among the opponents of the stroke-center concept during the 1990s was
Richard Stennes, then ER director at Paradise Valley Hospital south of
San Diego. In various public debates, Dr. Stennes recalls, he argued
that many apparent stroke patients would be siphoned away from
community hospitals even if they didn't turn out to have strokes. Also,
he argued that tPA might cause more injury than it prevents. And then
there was the economic issue: "Those hospitals without all the
equipment and stroke experts," he says, "would be concerned about all
the patients going to a stroke center and taking the patients away from
us." Dr. Stennes has since retired.

"All hospitals and clinicians try to deliver the right care to
patients, especially those with urgent medical needs," says Nancy E.
Foster, vice president for quality of the American Hospital
Association, which represents both large and small hospitals.
"Community hospitals may be equally good at delivering stroke care, and
it would be important for patients to know how well prepared their
local hospital is."

Stroke experts aren't proposing that every hospital needs to specialize
in stroke care but instead that in every population center there should
be at least one that does. In Atlanta, Emory University's
neuro-intensive care unit illustrates the special skills that make for
top care. Owen B. Samuels, director of the unit, estimates that 20% to
30% of patients it treats received poor initial medical care before
arriving at Emory, jeopardizing their futures or even lives. Brain
hemorrhages, for example, are commonly misdiagnosed, even in patients
who repeatedly showed up at emergency rooms with unusually severe
headaches, Dr. Samuels says.

The Emory unit has 30 staff members, including two neuro-critical care
doctors and five nurse practitioners. A team is on duty 24 hours a day.
The unit handles about two dozen patients most days, keeping the staff
busy. On the ward, nearly all patients are unconscious or sedated, so
it's eerily silent. Patients generally need to rest their brains as
they recover from stroke or surgery.

After a hemorrhagic stroke, blood pressure in the cranium builds as
blood continues to seep out of the ruptured vessel. Pressure can be
deadly, cutting off oxygen to the brain. Or escaped blood can cause a
"vasospasm," days after the original stroke, in which the brain reacts
violently to seeped-out blood. In the worst case, the brain herniates,
or squeezes out the base of the skull, causing death. To avoid this,
nurses at Emory constantly monitor brain pressure and temperatures.
They put in drain lines. They infuse medicines to dehydrate,
depressurize and stop bleeding.

Since Emory launched the neuro-intensive unit seven years ago, 42% of
patients with hemorrhagic strokes have become well enough to go home,
compared with 27% before. Fewer need rehabilitation -- 31% versus 40%
-- and the death rate is down.

Damica Townsend-Head, 33, gave the Emory team a scare. After surgery
last fall for a hemorrhagic stroke, her brain swelling was "really out
of control," Dr. Samuels says, raising questions about whether she
would survive. The staff put a "cooling catheter" into a blood vessel,
which allowed the circulation of ice water to bring down the
temperature in her blood and brain. They intentionally dehydrated her
brain to lower pressure. A month later, she woke up and recovered with
minimal disability. She still walks with a cane and tires easily, but
her speech is normal and she hopes to return soon to work. "I consider
her what we're in business for," Dr. Samuels says.

Public Awareness

The public's low awareness of stroke symptoms -- and the need to
respond immediately -- can also hinder proper care. Ischemic strokes,
those caused by clots or other artery blockage, cause symptoms such as
muscle weakness or paralysis on one side, slurred speech, facial droop,
severe dizziness, unstable gait and vision loss. People with this kind
of stroke are sometimes mistaken for being drunk. In addition to
intense head pain, a hemorrhagic stroke often leads to nausea, vomiting
or loss of balance or consciousness. Still, many people with some of
these symptoms merely go to bed in hopes of improving overnight,
doctors say. Instead, they should go immediately to a hospital and
demand a CT scan as a first diagnostic step.

The well-funded American Heart Association, established in 1924, has
made many people aware of heart attack symptoms and thereby saved many
lives. In contrast, the American Stroke Association was started only in
1998 as a subsidiary of the heart association. The stroke association
spent $162 million last year out of the heart association's $561
million overall budget.

Justin Zivin, another university of California at San Diego stroke
expert, says the stroke association "is a terribly ineffective bunch.
When it comes to actual public education, I haven't seen anything."

The stroke association counters that it is buying television and radio
ads promoting awareness, similar to ones produced in 2003 and 2004. The
group also sponsors research and education, including an annual
international stroke-medicine conference.

It's not just the general public that fails to recognize stroke
symptoms. Often, emergency-room doctors and nurses don't, either.
Gretchen Thiele of suburban Detroit began having horrible headaches
last May, for the first time in her life. "She wasn't one to complain,
but she said, 'I can't even lift my head off the pillow,' " recalls her
daughter, Erika Mazero. Ms. Thiele, 57, nearly passed out from the pain
one night and suffered blurred vision. When the pain recurred in the
morning, she went to the emergency room at nearby St. Joseph's Mercy of
Macomb Hospital. Ms. Mazero says that during the six hours her mother
spent there, she was given a CT scan, but not a spinal tap, which could
definitively have shown she had a leaking brain aneurysm, meaning a
ballooned and weakened artery in her brain. After the CT, Ms. Thiele
was given a muscle relaxant and pain medicine and sent home, her
daughter says.

Two months later, the blood vessel burst. Neurosurgeons at William
Beaumont Hospital in Royal Oak, Mich., did emergency surgery, but Ms.
Thiele suffered massive bleeding and died. Ali Bydon, one of the
neurosurgeons at Beaumont, says a CT scan often is inadequate and that
her condition could have been detected earlier with a spinal tap, also
called a lumbar puncture. "Had she had a lumbar puncture and perhaps an
operation earlier, it might have saved her life," says Dr. Bydon. "In
general, a person who tells you, 'I usually don't get headaches, and
this is the worst headache of my life,' is something that should alarm
you."

In addition, he says Ms. Thiele "absolutely" was experiencing
smaller-scale bleeding in May that foreshadowed a more serious rupture.
If doctors identify this kind of bleeding early, he says, chances of
death are "minimal." But when a rupture occurs, he says, "25% of
patients never make it to the hospital, 25% die in the hospital and 25%
are severely disabled."

A St. Joseph's hospital spokeswoman says the hospital has "very
aggressive standards for treatment, and we met this standard,"
declining to elaborate.

Determined Nurse

Paramedics did the right thing after Chuck Toeniskoetter's stroke, but
only because of some extraordinary intervention. Mr. Toeniskoetter,
then 55, was on a ski trip Dec. 23, 2000, at Bear Valley, near Los
Angeles. He had just finished a run at 3:30 p.m. when, in the
snowmobile shop, he began slurring his words and nearly fell over.
Kathy Snyder, the nurse in the ski area's first-aid room, quickly
diagnosed stroke. She called a helicopter and an ambulance.

Ms. Snyder says she knew the closest hospital with a stroke team was
Sutter Roseville Medical Center in Roseville, Calif. The helicopter
pilot was planning to take Mr. Toeniskoetter to a closer ER, but Ms.
Snyder says she stood on the helicopter runners, demanding the patient
go to Sutter. The pilot eventually relented. Mr. Toeniskoetter went to
Sutter, where he promptly received tPA. Today, he has no disability and
is back running a real estate-development business in the San Jose
area. "Trauma patients go to trauma centers, not the nearest hospital,"
he says. "Stroke victims, too, require a real specialized sort of
care."

One-third of all strokes are suffered by people under 60, and
hemorrhagic strokes in particular often strike young adults and
children. Vance Bowers of Orlando, Fla., was 9 when he woke up
screaming that his eyes hurt, shortly after 1 a.m. on Jan. 8, 2001.
Malformed blood vessels in his brain were bleeding. He was in a coma by
the time an ambulance delivered him at 1:57 a.m. to the nearest
emergency room, at Florida Hospital East Orlando.

Emergency-room doctors soon realized Vance had a hemorrhagic stroke.
But neurosurgery isn't performed at that hospital. A sister hospital 14
minutes away by ambulance, Florida Hospital Orlando, did have
neurosurgical capability. But in part because of administrative
tangles, Vance didn't get to the second hospital until 4:37 a.m., more
than two hours after his arrival. Surgery began at 6:18 a.m. "This
delay may have cost this young man the possibility of a functional
survival," Paul D. Sawin, the neurosurgeon who operated on Vance, said
in a letter to the hospitals' joint administration.

Florida Hospital, an emergency-medicine group and an ER doctor recently
agreed to settle a lawsuit filed against them in Orange County, Fla.,
Circuit Court by the Bowers family. The defendants agreed to pay a
total of $800,000, court records show. Monica Reed, senior medical
officer of the hospital, says the care Vance received was "stellar" and
that any delays weren't medically significant. Vance's stroke, not the
care he received, caused his injuries, she said.

Vance, now 13, survived but is mentally handicapped and suffers daily
seizures, his mother, Brenda Bowers, says. Once a star baseball player,
he goes by wheelchair to a class for disabled children. He speaks very
slowly but not in a way that many people can understand. "He remembers
playing baseball with all of his friends," his mother says, but they
rarely come around any more. "He really misses all that."

TwitteringOne

2005-05-18, 11:40 am

And there are differences in presentation,
based on gender, further complicating the problem of receiving
prompt, responsible treatment.

Jim Chinnis

2005-05-18, 11:40 am

"TwitteringOne" <mournenwould@aol.com> wrote in part:

>And there are differences in presentation,
>based on gender, further complicating the problem of receiving
>prompt, responsible treatment.

What differences might those be?
--
Jim Chinnis Warrenton, Virginia, USA

TwitteringOne

2005-05-18, 11:40 am

I'll have to get back to you.
Take an aspirin,
Call me next week.

Jim Chinnis

2005-05-18, 11:40 am

"TwitteringOne" <mournenwould@aol.com> wrote in part:

>I'll have to get back to you.
>Take an aspirin,
>Call me next week.

Take your time.
--
Jim Chinnis Warrenton, Virginia, USA

Bryan

2005-05-18, 11:40 am

MrPepper11 wrote:
<snip>

What's most scary about this , even though it's important to treat
stroke, is the ambulance negligence.

I'm a RN at a tertiary center in NY and just 3 days ago a coworker had a
family member who was about 18 miles from our hospital, but only 13 from
a troubled inferior community hospital, the pt specifically requested to
come to our hospital, fearing that she was having an MI. The ambulance
flatly refused to take her to our hospital telling her that it was
against ambulance company protocol. The pt specifically asked if the
ambulance driver felt the Dr.'s were better qualified to treat her where
they were taking her as opposed to where she wished to go. The EMT
answered "probably not". This is doubly troubling, since they now have
opened themselves up for a negligence lawsuit, which my friend has said
her grandmother will not pursue, but also more dangerously, if this
happens again the pt is more likely to attempt to drive themselves to
the facility they feel is more appropriate, rather than call for an
ambulance. I realize the need for expedience in transport of a pt. but
shouldn't common sense prevail in a case like this? It was clear the EMT
felt the pt was justified in her preference, why not take her to the
facility where she was going to receive superior care?

btw, once the pt was signed off by the ED MD as stable she was
transported to our facility for Cardiac Cath.

Williams

2005-05-18, 11:40 am

Bryan

2005-05-18, 11:40 am

Williams wrote:

> Bryan wrote:
>
>
> had a
>
>
> from
>
>
> to
>
>
> ambulance
>
>
> where
>
>
> have
>
>
> said
>
>
>
>
> but
>
>
> EMT
>
>
>
> if our health care is so screwed up such that people have to drive
> their loved ones to the right hospital capable of treating them, then
> maybe the medical community should publicize which is the correct
> hospital for people to go to.... now that you can't trust the ambulance
> companies anymore!!!
>
This is not entirely what I meant, but you do have a valid point.

I was not trying to imply that our ambulances can't be trusted, only
that the EMT's and Paramedics exercise a more critical thinking approach
to where they take their pt.s. A few extra seconds in the field to
assess the pt. and decide that a longer ambulance ride to a superior
facility is more beneficial than expedience for the sake of response
numbers.

Carey Gregory

2005-05-18, 11:40 am

Bryan <cyberbmcd@optonline.net> wrote:

>I was not trying to imply that our ambulances can't be trusted, only
>that the EMT's and Paramedics exercise a more critical thinking approach
>to where they take their pt.s. A few extra seconds in the field to
>assess the pt. and decide that a longer ambulance ride to a superior
>facility is more beneficial than expedience for the sake of response
>numbers.

The EMT stated the choice was dictated by company policy.

It's difficult to exercise critical thinking and good judgment when you will
lose your job for doing so.

Dave S

2005-05-18, 11:40 am

I can count on one hand with less than half of those fingers... the
number of credentialed "stroke centers" in Houston, Texas.. 4th largest
city in the US. There are over 20 hospitals in the area.

Dave

MrPepper11 wrote:
> A 2000 survey showed that 66% of hospitals in North Carolina lacked any
> protocol for treating stroke. 82% couldn't identify patients with acute
> stroke.
>
> May 9, 2005
> Stroke Victims Are Often Taken To Wrong Hospital
> Outdated Ambulance Rules, Inadequate ERs Make Dangerous Ailment Worse
> Lessons From Trauma Centers
> By THOMAS M. BURTON
> Staff Reporter of THE WALL STREET JOURNAL
>
> Christina Mei suffered a stroke just before noon on Sept. 2, 2001.
> Within eight minutes, an ambulance arrived. Her medical fate may have
> been sealed by where the ambulance took her.
>
> Ms. Mei's stroke, caused by a clot blocking blood flow to her brain,
> occurred while she was driving with her family south of San Francisco.
> Her car swerved, but she was able to pull over before slumping at the
> wheel. Paramedics saw the classic signs of a stroke: The 45-year-old
> driver couldn't speak or move the right side of her body.
>
> Had Ms. Mei's stroke occurred a few miles to the south, she probably
> would have been taken to Stanford university Medical Center, one of the
> world's top stroke hospitals. There, a neurologist almost certainly
> would have seen her quickly and administered an intravenous drug to
> dissolve the clot. Stanford was 17 miles away, across a county line.
>
> But paramedics, following county ambulance rules that stress proximity,
> took her 13 miles north, to Kaiser Permanente's South San Francisco
> Medical Center. There, despite her sudden inability to talk or walk and
> her facial droop, an emergency-room doctor concluded she was suffering
> from depression and stress. It was six hours before a neurologist saw
> her, and she never got the intravenous clot-dissolving drug.
>
> In a legal action brought against Kaiser on Ms. Mei's behalf, an
> arbitrator found that her care had been negligent, and in some aspects
> "incomprehensible." Today, Ms. Mei can't dress herself and walks
> unsteadily, says her lawyer, Richard C. Bennett. The fingers on her
> right hand are curled closed, and she has had to give up her main
> avocations: calligraphy, ceramics and other types of art. Kaiser
> declined to comment beyond saying that it settled the case under
> confidential terms "based on some concerns raised in the litigation."
>
> Stroke is the nation's No. 1 cause of disability and No. 3 cause of
> death, killing 164,000 people a year. But far too many stroke victims,
> like Ms. Mei, get inadequate care thanks to deficient medical training
> and outdated ambulance rules that don't send patients to the best
> stroke hospitals.
>
> Over the past decade, American medicine has learned how to save stroke
> patients' lives and keep them out of nursing homes. New techniques
> offer a better chance of complete recovery by dissolving blood clots
> and treating even more lethal strokes caused by burst blood vessels in
> the brain. But few patients receive this kind of treatment because most
> hospitals lack specialized staff and knowledge, stroke experts say.
> State and county rules generally require paramedics to take stroke
> patients to the nearest emergency room, regardless of that hospital's
> level of expertise with stroke.
>
> Stroke care is positioned roughly where trauma care was a
> quarter-century ago. By 1975, surgeons expert at treating victims of
> car crashes and other major accidents realized that taking severely
> injured patients to the nearest emergency room could mean death. So the
> surgeons led a push to make selected regional hospitals into
> specialized trauma centers and to overhaul ambulance protocols so that
> paramedics would speed the most severely injured to those centers. Now,
> in many areas of the U.S., accident victims go quickly to a trauma
> center, and trauma specialists say this change has saved lives and
> lessened disability.
>
> Eighty percent or more of the 700,000 strokes that Americans suffer
> annually are "ischemic," meaning they are caused by blockage of an
> artery feeding the brain, usually a blood clot. Most of the rest are
> "hemorrhagic" strokes, resulting from burst blood vessels in or near
> the brain. Although they have different causes, both result in brain
> tissue dying by the minute.
>
> Several factors have combined to prevent improvement in stroke care. In
> some areas, hospitals have resisted movement toward a system of
> specialized stroke centers because nondesignated institutions could
> lose business, according to neurologists who favor the changes. In
> addition, stroke treatment has lacked an organized lobby to galvanize
> popular and political interest in the ailment.
>
> Doctor Ignorance
>
> A big reason for the backwardness of much stroke treatment is that many
> doctors know little about it. Even emergency physicians and internists
> likely to see stroke victims tend to receive scant neurology training
> in their internships and residencies, according to stroke specialists.
>
> "Surprisingly, you could go through your entire internal-medicine
> rotation without training in neurology, and in emergency medicine it
> hasn't been emphasized," says James C. Grotta, director of the stroke
> program at the university of Texas Health Science Center at Houston.
>
> Many hospitals don't have a neurologist ready to deal with emergencies.
> As a result, strokes aren't treated urgently there, even though short
> delays increase chances of severe disability or death. Even if doctors
> do react quickly, recent research has shown that many aren't sure what
> treatment to provide.
>
> For example, a survey published in 2000 in the journal Stroke showed
> that 66% of hospitals in North Carolina lacked any protocol for
> treating stroke. About 82% couldn't rapidly identify patients with
> acute stroke.
>
> As with other life-threatening conditions, stroke patients are better
> off going where doctors have had a lot of practice addressing their
> ailment. A seven-year analysis of surgery in New York state in the
> 1990s showed that patients with ruptured blood vessels in the brain
> were more than twice as likely to die -- 16% versus 7% -- in hospitals
> doing few such operations, compared with those doing them regularly. A
> national study published last year in the Journal of Neurosurgery
> showed a similar disparity.
>
> Another major shortcoming of most stroke treatment, according to many
> neurologists, is the failure to use the genetically engineered
> clot-dissolving drug known as tPA. Short for tissue plasminogen
> activator, tPA, which is made by Genentech Inc., has been shown to be a
> powerful treatment that can lessen disability for many patients. A
> study published in 2004 in The Lancet, a prominent medical journal,
> showed that the chances of returning to normal are about three times
> greater among patients getting tPA in the first 90 minutes after
> suffering a stroke, even after accounting for tPA's potential side
> effect of cerebral bleeding that can cause death. But several recent
> medical-journal articles have found that nationally, only 2% to 3% of
> strokes caused by clots are treated with tPA, which has no competitor
> on the market.
>
> Some authors of studies supporting the use of tPA have had consultant
> or other financial relationships with Genentech. Skeptics of the drug
> point to these ties and stress tPA's side-effect danger. But among
> stroke neurologists, there is a strong consensus that the drug is
> effective.
>
> One reason why many patients don't receive tPA is that they arrive at
> the hospital more than three hours after a stroke, the time period
> during which intravenous tPA should be given. But many hospitals and
> doctors don't use tPA at all, even though it has been available in the
> U.S. since 1996. The dissolving agent's relatively high cost -- $2,000
> or more per patient -- is a barrier. Medicare pays hospitals a flat
> reimbursement of about $5,700 for stroke treatment, regardless of
> whether tPA is used.
>
> Airport Emergency
>
> Glender Shelton of Houston had an ischemic stroke caused by a clot at
> Los Angeles International Airport on Dec. 30, 2003. In full view of
> other holiday travelers, Ms. Shelton, then 66, slumped over, and an
> ambulance was called. It was 4:45 p.m.
>
> By 5:55 p.m., she arrived at what now is called Centinela Freeman
> Regional Medical Center, four miles away in Marina del Rey. Hospital
> records show that doctors thought Ms. Shelton had suffered an "acute
> stroke." But she didn't get a CT scan, a recommended initial step,
> until 9 p.m. By then, she was already outside the three-hour window for
> safely administering intravenous tPA. Records also say she didn't
> receive the drug "due to unavailability of a neurologist until after
> the patient had been outside the three-hour time window."
>
> Ms. Shelton's daughter, Sandi Shaw, was until recently nurse-manager of
> the prestigious stroke unit at the university of Texas Health Science
> Center at Houston. Ms. Shaw says that at her unit, her mother would
> have had a CT scan within five minutes of arriving, and tPA probably
> would have been administered 30 or 35 minutes after that.
>
> Today, according to her daughter. Ms. Shelton often can't come up with
> words or relatives' names, can't take care of her finances, and can't
> follow certain basic commands in neurological tests.
>
> Kent Shoji, an emergency-room doctor at Centinela Freeman who handled
> Ms. Shelton's case, says, "She was a possible candidate for tPA," but a
> CT scan was required first. "The order was put in for a CT scan," Dr.
> Shoji says. "I can't answer why it took so long."
>
> A Centinela Freeman spokeswoman says, "We did not have 24/7 coverage
> with our CT scan, and we had to call a technician to come in. That's
> pretty common with a community hospital." The hospital has since been
> acquired by a larger health system and now does have 24-hour CT
> capability.
>
> 'Parochial Interests'
>
> A hospital-accrediting group has begun designating hospitals as stroke
> centers, but that is only part of what is needed, stroke experts
> assert. They say hospitals typically have to come together to create
> local political momentum to change state or county rules so that
> ambulances actually take stroke patients to stroke centers, not the
> nearest ER. New York, Maryland and Massachusetts are moving toward
> creating stroke-care systems, and Florida recently passed a law
> creating stroke centers. But in many places, short-term economic
> interests impede change, some doctors say.
>
> "There are still very parochial interests by hospitals and physicians
> to keep patients locally even if they're not equipped to handle them,"
> says neurosurgeon Robert A. Solomon of New York-Presbyterian
> Hospital/Columbia. "Hospitals don't want to give up patients."
>
> The university of California at San Diego runs one of the leading
> stroke hospitals in the country. It and others in the area that are
> well prepared to treat stroke patients have sought for a decade to set
> up a regional system, but there has been little progress, says Patrick
> D. Lyden, UCSD's chief of neurology. "Some hospitals are resisting
> losing stroke business," he says. "We have the same political crap as
> in most communities. Paramedics still take people to the local ER."
>
> Among the opponents of the stroke-center concept during the 1990s was
> Richard Stennes, then ER director at Paradise Valley Hospital south of
> San Diego. In various public debates, Dr. Stennes recalls, he argued
> that many apparent stroke patients would be siphoned away from
> community hospitals even if they didn't turn out to have strokes. Also,
> he argued that tPA might cause more injury than it prevents. And then
> there was the economic issue: "Those hospitals without all the
> equipment and stroke experts," he says, "would be concerned about all
> the patients going to a stroke center and taking the patients away from
> us." Dr. Stennes has since retired.
>
> "All hospitals and clinicians try to deliver the right care to
> patients, especially those with urgent medical needs," says Nancy E.
> Foster, vice president for quality of the American Hospital
> Association, which represents both large and small hospitals.
> "Community hospitals may be equally good at delivering stroke care, and
> it would be important for patients to know how well prepared their
> local hospital is."
>
> Stroke experts aren't proposing that every hospital needs to specialize
> in stroke care but instead that in every population center there should
> be at least one that does. In Atlanta, Emory University's
> neuro-intensive care unit illustrates the special skills that make for
> top care. Owen B. Samuels, director of the unit, estimates that 20% to
> 30% of patients it treats received poor initial medical care before
> arriving at Emory, jeopardizing their futures or even lives. Brain
> hemorrhages, for example, are commonly misdiagnosed, even in patients
> who repeatedly showed up at emergency rooms with unusually severe
> headaches, Dr. Samuels says.
>
> The Emory unit has 30 staff members, including two neuro-critical care
> doctors and five nurse practitioners. A team is on duty 24 hours a day.
> The unit handles about two dozen patients most days, keeping the staff
> busy. On the ward, nearly all patients are unconscious or sedated, so
> it's eerily silent. Patients generally need to rest their brains as
> they recover from stroke or surgery.
>
> After a hemorrhagic stroke, blood pressure in the cranium builds as
> blood continues to seep out of the ruptured vessel. Pressure can be
> deadly, cutting off oxygen to the brain. Or escaped blood can cause a
> "vasospasm," days after the original stroke, in which the brain reacts
> violently to seeped-out blood. In the worst case, the brain herniates,
> or squeezes out the base of the skull, causing death. To avoid this,
> nurses at Emory constantly monitor brain pressure and temperatures.
> They put in drain lines. They infuse medicines to dehydrate,
> depressurize and stop bleeding.
>
> Since Emory launched the neuro-intensive unit seven years ago, 42% of
> patients with hemorrhagic strokes have become well enough to go home,
> compared with 27% before. Fewer need rehabilitation -- 31% versus 40%
> -- and the death rate is down.
>
> Damica Townsend-Head, 33, gave the Emory team a scare. After surgery
> last fall for a hemorrhagic stroke, her brain swelling was "really out
> of control," Dr. Samuels says, raising questions about whether she
> would survive. The staff put a "cooling catheter" into a blood vessel,
> which allowed the circulation of ice water to bring down the
> temperature in her blood and brain. They intentionally dehydrated her
> brain to lower pressure. A month later, she woke up and recovered with
> minimal disability. She still walks with a cane and tires easily, but
> her speech is normal and she hopes to return soon to work. "I consider
> her what we're in business for," Dr. Samuels says.
>
> Public Awareness
>
> The public's low awareness of stroke symptoms -- and the need to
> respond immediately -- can also hinder proper care. Ischemic strokes,
> those caused by clots or other artery blockage, cause symptoms such as
> muscle weakness or paralysis on one side, slurred speech, facial droop,
> severe dizziness, unstable gait and vision loss. People with this kind
> of stroke are sometimes mistaken for being drunk. In addition to
> intense head pain, a hemorrhagic stroke often leads to nausea, vomiting
> or loss of balance or consciousness. Still, many people with some of
> these symptoms merely go to bed in hopes of improving overnight,
> doctors say. Instead, they should go immediately to a hospital and
> demand a CT scan as a first diagnostic step.
>
> The well-funded American Heart Association, established in 1924, has
> made many people aware of heart attack symptoms and thereby saved many
> lives. In contrast, the American Stroke Association was started only in
> 1998 as a subsidiary of the heart association. The stroke association
> spent $162 million last year out of the heart association's $561
> million overall budget.
>
> Justin Zivin, another university of California at San Diego stroke
> expert, says the stroke association "is a terribly ineffective bunch.
> When it comes to actual public education, I haven't seen anything."
>
> The stroke association counters that it is buying television and radio
> ads promoting awareness, similar to ones produced in 2003 and 2004. The
> group also sponsors research and education, including an annual
> international stroke-medicine conference.
>
> It's not just the general public that fails to recognize stroke
> symptoms. Often, emergency-room doctors and nurses don't, either.
> Gretchen Thiele of suburban Detroit began having horrible headaches
> last May, for the first time in her life. "She wasn't one to complain,
> but she said, 'I can't even lift my head off the pillow,' " recalls her
> daughter, Erika Mazero. Ms. Thiele, 57, nearly passed out from the pain
> one night and suffered blurred vision. When the pain recurred in the
> morning, she went to the emergency room at nearby St. Joseph's Mercy of
> Macomb Hospital. Ms. Mazero says that during the six hours her mother
> spent there, she was given a CT scan, but not a spinal tap, which could
> definitively have shown she had a leaking brain aneurysm, meaning a
> ballooned and weakened artery in her brain. After the CT, Ms. Thiele
> was given a muscle relaxant and pain medicine and sent home, her
> daughter says.
>
> Two months later, the blood vessel burst. Neurosurgeons at William
> Beaumont Hospital in Royal Oak, Mich., did emergency surgery, but Ms.
> Thiele suffered massive bleeding and died. Ali Bydon, one of the
> neurosurgeons at Beaumont, says a CT scan often is inadequate and that
> her condition could have been detected earlier with a spinal tap, also
> called a lumbar puncture. "Had she had a lumbar puncture and perhaps an
> operation earlier, it might have saved her life," says Dr. Bydon. "In
> general, a person who tells you, 'I usually don't get headaches, and
> this is the worst headache of my life,' is something that should alarm
> you."
>
> In addition, he says Ms. Thiele "absolutely" was experiencing
> smaller-scale bleeding in May that foreshadowed a more serious rupture.
> If doctors identify this kind of bleeding early, he says, chances of
> death are "minimal." But when a rupture occurs, he says, "25% of
> patients never make it to the hospital, 25% die in the hospital and 25%
> are severely disabled."
>
> A St. Joseph's hospital spokeswoman says the hospital has "very
> aggressive standards for treatment, and we met this standard,"
> declining to elaborate.
>
> Determined Nurse
>
> Paramedics did the right thing after Chuck Toeniskoetter's stroke, but
> only because of some extraordinary intervention. Mr. Toeniskoetter,
> then 55, was on a ski trip Dec. 23, 2000, at Bear Valley, near Los
> Angeles. He had just finished a run at 3:30 p.m. when, in the
> snowmobile shop, he began slurring his words and nearly fell over.
> Kathy Snyder, the nurse in the ski area's first-aid room, quickly
> diagnosed stroke. She called a helicopter and an ambulance.
>
> Ms. Snyder says she knew the closest hospital with a stroke team was
> Sutter Roseville Medical Center in Roseville, Calif. The helicopter
> pilot was planning to take Mr. Toeniskoetter to a closer ER, but Ms.
> Snyder says she stood on the helicopter runners, demanding the patient
> go to Sutter. The pilot eventually relented. Mr. Toeniskoetter went to
> Sutter, where he promptly received tPA. Today, he has no disability and
> is back running a real estate-development business in the San Jose
> area. "Trauma patients go to trauma centers, not the nearest hospital,"
> he says. "Stroke victims, too, require a real specialized sort of
> care."
>
> One-third of all strokes are suffered by people under 60, and
> hemorrhagic strokes in particular often strike young adults and
> children. Vance Bowers of Orlando, Fla., was 9 when he woke up
> screaming that his eyes hurt, shortly after 1 a.m. on Jan. 8, 2001.
> Malformed blood vessels in his brain were bleeding. He was in a coma by
> the time an ambulance delivered him at 1:57 a.m. to the nearest
> emergency room, at Florida Hospital East Orlando.
>
> Emergency-room doctors soon realized Vance had a hemorrhagic stroke.
> But neurosurgery isn't performed at that hospital. A sister hospital 14
> minutes away by ambulance, Florida Hospital Orlando, did have
> neurosurgical capability. But in part because of administrative
> tangles, Vance didn't get to the second hospital until 4:37 a.m., more
> than two hours after his arrival. Surgery began at 6:18 a.m. "This
> delay may have cost this young man the possibility of a functional
> survival," Paul D. Sawin, the neurosurgeon who operated on Vance, said
> in a letter to the hospitals' joint administration.
>
> Florida Hospital, an emergency-medicine group and an ER doctor recently
> agreed to settle a lawsuit filed against them in Orange County, Fla.,
> Circuit Court by the Bowers family. The defendants agreed to pay a
> total of $800,000, court records show. Monica Reed, senior medical
> officer of the hospital, says the care Vance received was "stellar" and
> that any delays weren't medically significant. Vance's stroke, not the
> care he received, caused his injuries, she said.
>
> Vance, now 13, survived but is mentally handicapped and suffers daily
> seizures, his mother, Brenda Bowers, says. Once a star baseball player,
> he goes by wheelchair to a class for disabled children. He speaks very
> slowly but not in a way that many people can understand. "He remembers
> playing baseball with all of his friends," his mother says, but they
> rarely come around any more. "He really misses all that."
>

Bob Ward

2005-05-18, 11:40 am

On Mon, 09 May 2005 16:01:48 -0400, Bryan <cyberbmcd@optonline.net>
wrote:

>Williams wrote:
>
>This is not entirely what I meant, but you do have a valid point.
>
>I was not trying to imply that our ambulances can't be trusted, only
>that the EMT's and Paramedics exercise a more critical thinking approach
>to where they take their pt.s. A few extra seconds in the field to
>assess the pt. and decide that a longer ambulance ride to a superior
>facility is more beneficial than expedience for the sake of response
>numbers.

More beneficial for who? The longer ride certainly makes the
ambulance company healthier, but doesn't necessarily mean things are
better for the patient.

That''s why I think the original poster was off base - the ambulance
is paid by the mile - they have no reason to go to the closest
facility for expedience.

HorneTD

2005-05-18, 11:40 am

Bryan wrote:
> MrPepper11 wrote:
> <snip>
>
> What's most scary about this , even though it's important to treat
> stroke, is the ambulance negligence.
>
> I'm a RN at a tertiary center in NY and just 3 days ago a coworker had a
> family member who was about 18 miles from our hospital, but only 13 from
> a troubled inferior community hospital, the pt specifically requested to
> come to our hospital, fearing that she was having an MI. The ambulance
> flatly refused to take her to our hospital telling her that it was
> against ambulance company protocol. The pt specifically asked if the
> ambulance driver felt the Dr.'s were better qualified to treat her where
> they were taking her as opposed to where she wished to go. The EMT
> answered "probably not". This is doubly troubling, since they now have
> opened themselves up for a negligence lawsuit, which my friend has said
> her grandmother will not pursue, but also more dangerously, if this
> happens again the pt is more likely to attempt to drive themselves to
> the facility they feel is more appropriate, rather than call for an
> ambulance. I realize the need for expedience in transport of a pt. but
> shouldn't common sense prevail in a case like this? It was clear the EMT
> felt the pt was justified in her preference, why not take her to the
> facility where she was going to receive superior care?
>
> btw, once the pt was signed off by the ED MD as stable she was
> transported to our facility for Cardiac Cath.

Both you and the person who posted the original article are missing a
critical piece of information. The Hospital that the ambulance must
take you to is not decided by the ambulance staff. Depending on who
operates the ambulance the choice may be made by an insurance
administrator, a medical control physician, a county emergency medical
service committee, or even a state wide certifying organization. I
volunteer on a public ambulance. It is owned and operated by the county
government. There is a state wide certifying agency that has identified
which hospitals are to be considered specialty referral centers and for
what conditions. The counties present transport policy is that in the
absence of an eligible specialty referral condition the choice of
hospital may not add more than ten minutes to the transport when
compared to the closest emergency department. The State agency
recognizes trauma, including specific types of trauma such as hand and
eye, and burns as specialty referral issues. Rape is not recognized,
nor is special medical devices, non traumatic pediatrics, sickle cell
anemia crisis, and many other conditions are not recognized. Public
ambulances are operated for the best interest of the public rather than
for the best interest of the individual patient. "The needs of the many
outweigh the needs of the few or the one." The publics best interest is
served by minimizing the time that their closest ambulance is tied up on
another call. A much higher priority is placed on the first five
minutes than the first five hours.

The problem that many public EMS systems have is system abuse. People
who have no health care use the ambulance and the Hill Burton amendment
as their primary health care resource. Policies that require that
patient or physician preference be given a higher priority than public
safety are almost always abused. The District of Columbia has a policy
of providing it's citizens transport to any hospital within the city
boundary. I have answered mutual aid calls there were patients expected
to be transported across the city at rush hour to a hospital they
preferred and the families always become verbally abusive and sometimes
physically threatening when informed that we are not permitted to do
that. The city has given them the expectation that they can demand
these choices and left their neighboring jurisdictions to cope with that
when those residents cross the city line into Maryland or answer the
cities calls for mutual aid.

I don't want to get lost in a diatribe here but I do want you to
understand that it is very seldom the ambulance staff that is making the
choice. It has usually been made in advance for them by insurance,
political, or financial interests.
--
Tom H

Bryan

2005-05-18, 11:40 am

Carey Gregory wrote:
> Bryan <cyberbmcd@optonline.net> wrote:
>
>
>
>
> The EMT stated the choice was dictated by company policy.
>
> It's difficult to exercise critical thinking and good judgment when you will
> lose your job for doing so.
>
clarification, the EMT works for a volunteer Fire Dept. with an
ambulance crew. You can't fire a volunteer.

Besides anyone choosing to save a life over company policy has their
head on straight.

If I lose my job simply because I didn't follow company policy the
company was not worth working for.

Bryan

2005-05-18, 11:40 am

Bob Ward wrote:

> On Mon, 09 May 2005 16:01:48 -0400, Bryan <cyberbmcd@optonline.net>
> wrote:
>
>
>
>
>
> More beneficial for who? The longer ride certainly makes the
> ambulance company healthier, but doesn't necessarily mean things are
> better for the patient.
>
> That''s why I think the original poster was off base - the ambulance
> is paid by the mile - they have no reason to go to the closest
> facility for expedience.
yes they do, most ambulance companies in this area of NY are volunteer,
they're not being paid. It's a company's response time that's at stake.
if they deliver the pt later than they are supposed to it looks like the
pt wasn't delivered to a hospital in a timely manner.

Bryan

2005-05-18, 11:40 am

HorneTD wrote:

> Bryan wrote:
>
>
>
> Both you and the person who posted the original article are missing a
> critical piece of information. The Hospital that the ambulance must
> take you to is not decided by the ambulance staff. Depending on who
> operates the ambulance the choice may be made by an insurance
> administrator, a medical control physician, a county emergency medical
> service committee, or even a state wide certifying organization. I
> volunteer on a public ambulance. It is owned and operated by the county
> government. There is a state wide certifying agency that has identified
> which hospitals are to be considered specialty referral centers and for
> what conditions. The counties present transport policy is that in the
> absence of an eligible specialty referral condition the choice of
> hospital may not add more than ten minutes to the transport when
> compared to the closest emergency department. The State agency
> recognizes trauma, including specific types of trauma such as hand and
> eye, and burns as specialty referral issues. Rape is not recognized,
> nor is special medical devices, non traumatic pediatrics, sickle cell
> anemia crisis, and many other conditions are not recognized. Public
> ambulances are operated for the best interest of the public rather than
> for the best interest of the individual patient. "The needs of the many
> outweigh the needs of the few or the one." The publics best interest is
> served by minimizing the time that their closest ambulance is tied up on
> another call. A much higher priority is placed on the first five
> minutes than the first five hours.
>
> The problem that many public EMS systems have is system abuse. People
> who have no health care use the ambulance and the Hill Burton amendment
> as their primary health care resource. Policies that require that
> patient or physician preference be given a higher priority than public
> safety are almost always abused. The District of Columbia has a policy
> of providing it's citizens transport to any hospital within the city
> boundary. I have answered mutual aid calls there were patients expected
> to be transported across the city at rush hour to a hospital they
> preferred and the families always become verbally abusive and sometimes
> physically threatening when informed that we are not permitted to do
> that. The city has given them the expectation that they can demand
> these choices and left their neighboring jurisdictions to cope with that
> when those residents cross the city line into Maryland or answer the
> cities calls for mutual aid.
>
> I don't want to get lost in a diatribe here but I do want you to
> understand that it is very seldom the ambulance staff that is making the
> choice. It has usually been made in advance for them by insurance,
> political, or financial interests.
> --
> Tom H
That's all well and good but I still feel a judgment call by the
Paramedic or EMT should still prevail, especially in my area which is
also covered by public ambulances, there are enough districts close
enough to each other to facilitate tying up an ambulance if it means the
pt has a better chance at survival by getting the right treatment, not
necessarily the fastest.

HorneTD

2005-05-18, 11:40 am

Bryan wrote:
> HorneTD wrote:
>
>
> That's all well and good but I still feel a judgment call by the
> Paramedic or EMT should still prevail, especially in my area which is
> also covered by public ambulances, there are enough districts close
> enough to each other to facilitate tying up an ambulance if it means the
> pt has a better chance at survival by getting the right treatment, not
> necessarily the fastest.
If your system allows you that latitude then fine but many do not.
--
Tom H

Sharon Hope

2005-05-18, 11:40 am

While we are counting, how many hospitals include looking for a history of
statins in evaluating amnesia? Amnesia due to statins is listed on the PI,
well known in the literature, documented in Dr. Graveline's books and
interviews, and statins use is so widespread, yet how many hospitals even
consider the statin when a patient presents with amnesia?

"Dave S" <DoggtyredRN@earthlink.net> wrote in message
news:xzRfe.93$OU1.60@newsread3.news.pas.earthlink.net...
>I can count on one hand with less than half of those fingers... the number
>of credentialed "stroke centers" in Houston, Texas.. 4th largest city in
>the US. There are over 20 hospitals in the area.
>
> Dave
>
> MrPepper11 wrote:
>

Bryan

2005-05-18, 11:40 am

HorneTD wrote:

>
> If your system allows you that latitude then fine but many do not.
> --

Well yeah, that was my point, the systems need to allow that latitude.

lenny fackler

2005-05-18, 11:40 am

Williams wrote:
> Bryan wrote:
> had a
> from
requested[vbcol=seagreen]
> to
> ambulance
the[vbcol=seagreen]
> where
> have
> said
to[vbcol=seagreen]
>
> but
the[vbcol=seagreen]
> EMT
the[vbcol=seagreen]
>
> if our health care is so screwed up such that people have to drive
> their loved ones to the right hospital capable of treating them, then
> maybe the medical community should publicize which is the correct
> hospital for people to go to

This is happening. Soon you will be able to compare hospitals on basic
quality of care measures.

HorneTD

2005-05-18, 11:40 am

Bryan wrote:
> HorneTD wrote:
>
>
>
> Well yeah, that was my point, the systems need to allow that latitude.

Bryan
You seem to think I disagree with you. I don't! All I'm trying to say
is that the forces that effect those decisions are well beyond the
control of the field staff and are likely to remain so. Much more
importantly the field staff are not to blame for the damnable politics
and greed that actually shape those decisions.
--
Tom Horne

Bryan

2005-05-18, 11:40 am

HorneTD wrote:

> Bryan wrote:
>
><snip>

>
>
> Bryan
> You seem to think I disagree with you. I don't! All I'm trying to say
> is that the forces that effect those decisions are well beyond the
> control of the field staff and are likely to remain so. Much more
> importantly the field staff are not to blame for the damnable politics
> and greed that actually shape those decisions.
> --
> Tom Horne

How did you get the impression I disagree with you? I said you made my
point....... anyway,

What I think is that you ARE partly correct: "the forces that effect
those decisions are well beyond the control of the field staff and are
likely to remain so."
My point is that the Field staff should be given the leeway to make
these kind of decisions. Especially if a Paramedic is involved in the
situation. Paramedics are trained in Critical Thinking and would
certainly be capable of a decision of this nature.

Carey Gregory

2005-05-18, 11:40 am

Bob Ward <bobward@verizon.net> wrote:

>That''s why I think the original poster was off base - the ambulance
>is paid by the mile - they have no reason to go to the closest
>facility for expedience.

They would here. Although there's a mileage fee, the base fee and ALS
surcharge far outweigh it. Getting back in service quickly for another call
is worth far more than a few extra billable miles, at least in urban systems
where transports tend to be fairly short.

I think the OP's point is perfectly valid. Where's he's off base is blaming
the crew when it was probably a policy they have no control over.

HorneTD

2005-05-18, 11:40 am

> HorneTD wrote:
>
> Bryan wrote:
> How did you get the impression I disagree with you? I said you made my
> point....... anyway,
>
> What I think is that you ARE partly correct: "the forces that effect
> those decisions are well beyond the control of the field staff and are
> likely to remain so."
> My point is that the Field staff should be given the leeway to make
> these kind of decisions. Especially if a Paramedic is involved in the
> situation. Paramedics are trained in Critical Thinking and would
> certainly be capable of a decision of this nature.

Bryan
If your going to try to make sense of this I will have to remind you
that North American emergency service practices are guided by three
hundred years of tradition uninterrupted by progress. If the paramedic
could decide that the patient would be better off at a different
facility then the closest hospital will be deprived of the opportunity
to biopsy the patients wallet and only transfer them if the biopsy comes
back negative for blue cross or other high pay out health insurance. On
top of that a Maryland trauma patient might end up at a District of
Columbia Hospital that is only ten minutes away by land rather than
going by helicopter to Bethesda or Baltimore thus loosing money to
another jurisdictions system that is run by a former protege of the
Maryland systems founder who had the audacity to strike out on his
own... OH NEVER MIND.
--
Tom H

Carey Gregory

2005-05-18, 11:40 am

Bryan <cyberbmcd@optonline.net> wrote:

>clarification, the EMT works for a volunteer Fire Dept. with an
>ambulance crew. You can't fire a volunteer.

Like hell you can't. I do it all the time.

>Besides anyone choosing to save a life over company policy has their
>head on straight.
>
>If I lose my job simply because I didn't follow company policy the
>company was not worth working for.

Let's try to keep the dramatics about saving lives within the realm of
reason, okay? We're talking optimal treatment here, not immediate life or
death. Even the best system has flaws, and the people who work in that
system, be they paid or volunteer, have no choice but work within the system
or get out. Or worse: be sued, stripped of their certification, or even
prosecuted. Volunteers are by no means immune to those consequences.

When a life is truly at stake, I won't hesitate to break regulations and do
what I think is necessary. But my butt will be on the line to prove I made
the right decision when I do that, so it's not a decision made lightly. "I
thought she would be better off at Hospital A than Hospital B" is a pretty
damned poor justification unless there's regulation, policy, or legislation
in place to support my *opinion* that Hospital A is better.

Basically, I agree with you that stroke patients would benefit from a system
similar to that established for trauma patients, but until those systems
exist and are sanctioned by governmental authority, it's just not practical
to expect EMTs to ignore the regulations and policies that govern them.

Carey Gregory

2005-05-18, 11:40 am

HorneTD <hornetd@mindspring.com> wrote:

> OH NEVER MIND.

lol.... Oh, c'mon, Tom, go ahead and explain it. How hard can it be?

Bryan

2005-05-18, 11:40 am

HorneTD wrote:

>
>
>
> Bryan
> If your going to try to make sense of this I will have to remind you
> that North American emergency service practices are guided by three
> hundred years of tradition uninterrupted by progress. If the paramedic
> could decide that the patient would be better off at a different
> facility then the closest hospital will be deprived of the opportunity
> to biopsy the patients wallet and only transfer them if the biopsy comes
> back negative for blue cross or other high pay out health insurance. On
> top of that a Maryland trauma patient might end up at a District of
> Columbia Hospital that is only ten minutes away by land rather than
> going by helicopter to Bethesda or Baltimore thus loosing money to
> another jurisdictions system that is run by a former protege of the
> Maryland systems founder who had the audacity to strike out on his
> own... OH NEVER MIND.
> --
> Tom H

I do understand, but in my case as presented all the hospitals were in
the same county. True though, our point remains the same , it seems the
ambulance companies care more about protocol and expedience that the
actual care of the pt.

Dave S

2005-05-18, 11:40 am

Pardon me, but what does that have to do with the ACUTE treatment of an
ischemic stroke?

Dave

Sharon Hope wrote:
> While we are counting, how many hospitals include looking for a history of
> statins in evaluating amnesia? Amnesia due to statins is listed on the PI,
> well known in the literature, documented in Dr. Graveline's books and
> interviews, and statins use is so widespread, yet how many hospitals even
> consider the statin when a patient presents with amnesia?
>
>
> "Dave S" <DoggtyredRN@earthlink.net> wrote in message
> news:xzRfe.93$OU1.60@newsread3.news.pas.earthlink.net...
>
>
>

HorneTD

2005-05-18, 11:40 am

Bryan wrote:
> HorneTD wrote:
>
>
>
>
> I do understand, but in my case as presented all the hospitals were in
> the same county. True though, our point remains the same , it seems the
> ambulance companies care more about protocol and expedience that the
> actual care of the pt.

You sir are one stubborn SOB. You insist on blaming the field staff and
the providing organization for policies over which they have no control.
You're right of Course
You're right of Course
You're right of Course
You're right of Course
You're right of Course
You're right of Course
You're right of Course
Happy now.
GO AWAY. I SAY GO AWAY BOY YA BOTHER ME. SCAT.
--
Ton Horne

Poppy - San Francisco Bay Area

2005-05-18, 11:40 am

Here are the symptoms of stroke according to the American Stroke Assn:

-Sudden numbness or weakness of the face, arm or leg, especially on one
side of the body
-Sudden confusion, trouble speaking or understanding
-Sudden trouble seeing in one or both eyes
-Sudden trouble walking, dizziness, loss of balance or coordination
-Sudden, severe headache with no known cause

DollarBill

2005-05-18, 11:40 am

"Bryan" <cyberbmcd@optonline.net> wrote in message
news:yB8ge.113$yx.42@fe08.lga...

<snip>

> Paramedics are trained in Critical Thinking

Now this is a real can of worms here!! Critical Thinking? Check this:
http://www.google.com/search?hl=en&...itical+thinking

Perhaps the best one I found on the reference page was:
"Critical thinking is a process that challenges an individual to use
reflective, reasonable, rational thinking to gather, interpret and evaluate
information in order to derive a judgment. The process involves thinking
beyond a single solution for a problem and focusing on deciding what the
best alternatives are."

The problem is that many paramedics I know cannot or will not use their
training and experience to properly assess a patient. I think they are
fearful of having to defend themselves and defend their judgments and
instead rely on the protocols to absolutely dictate treatment methods. I
have been taught from the beginning that protocols are guidelines and if a
treatment method falls outside the protocol but can be shown to have
clinical significance, it is justified as long as it remains within the
scope of practice.

As for deviating from the nearest facility based on your assessment of the
patient, your medical director should have a list of hospital capabilities
and your deviation from the nearest facility should be predicated on your
proper assessment.
--
Gotta Go...It's Hot In Here,
William Lyster-FF/NREMTB

Bryan

2005-05-18, 11:40 am

HorneTD wrote:

<snip>
>
>
> You sir are one stubborn SOB. You insist on blaming the field staff and
> the providing organization for policies over which they have no control.

Stubborn? maybe. But you are incorrect. the field staff and the
providing organization most certainly DO have control, they just fail to
exercise it. Big difference.

> You're right of Course
> You're right of Course
> You're right of Course
> You're right of Course
> You're right of Course
> You're right of Course
> You're right of Course
> Happy now.

No, sarcasm is most annoying the only one who derives joy from it is the
provider.

> GO AWAY. I SAY GO AWAY BOY YA BOTHER ME. SCAT.

I'm sorry. I don't remember asking if I bothered you, you could always
choose not to read my posts, or better yet choose not to respond...........

BKM RN

Bryan

2005-05-18, 11:40 am

HorneTD wrote:

> DollarBill wrote:
>
>
>
> Bill
> You get it because you are a field provider. "your medical director
> should have a list of hospital capabilities" does kind of say it all. We
> are not permitted to make up rules as we go along. Bryan insists that
> we can and should.
> --
> Tom Horne

I get it too sir, you just choose to hide behind your incessant whining
"stop blaming me." or "stop blaming those in the field." or "stop
blaming the ambulance companies for being arrogant and shortsighted."

Bill said: your medical director should have a list of hospital
capabilities and your deviation from the nearest facility should be
predicated on your proper assessment.

This is exactly what I have been saying all along, no different.
the problem is in the OP and my example this ISN'T what happened. Do
you get it now?

Carey Gregory

2005-05-18, 11:40 am

Bryan <cyberbmcd@optonline.net> wrote:
>
>I get it too sir, you just choose to hide behind your incessant whining
>"stop blaming me." or "stop blaming those in the field." or "stop
>blaming the ambulance companies for being arrogant and shortsighted."

Well, you really should stop it.

You seem unwilling to accept the reality that in the vast majority of cases
there is absolutely *no objective basis* on which to justify bypassing a
closer hospital for another in cases of stroke.

>Bill said: your medical director should have a list of hospital
>capabilities and your deviation from the nearest facility should be
>predicated on your proper assessment.

All hospitals within my coverage area offer stroke management and
neurosurgery. Now, which ones do you think I should bypass, and on what
basis? Sure, I know which one I'd want my relative at, but my personal
opinion carries little weight at the department of health, and even less in
court. Hell, even the hospitals being bypassed might file complaints once
they learned what was happening.

Bryan

2005-05-18, 11:40 am

Carey Gregory wrote:

> Bryan <cyberbmcd@optonline.net> wrote:
>
>
>
> Well, you really should stop it.
>
> You seem unwilling to accept the reality that in the vast majority of cases
> there is absolutely *no objective basis* on which to justify bypassing a
> closer hospital for another in cases of stroke.
>
>

Maybe, but the case I used as an example was for MI not stroke, and in
that case there is an objective basis to justify bringing someone to a
known cardiac facility over a community hospital.

>
>
> All hospitals within my coverage area offer stroke management and
> neurosurgery. Now, which ones do you think I should bypass, and on what
> basis? Sure, I know which one I'd want my relative at, but my personal
> opinion carries little weight at the department of health, and even less in
> court. Hell, even the hospitals being bypassed might file complaints once
> they learned what was happening.
>
That may very well be the case in your situation, it is not in all
others. In my county people are routinely driven to closer hospitals
solely for the purpose of expedience, even if a facility only a little
farther away is the better choice.
Again, I am not blaming the field personnel, I never did. I blame their
superiors for not allowing them to make their own choices in these
situations.

Carey Gregory

2005-05-18, 11:40 am

Bryan <cyberbmcd@optonline.net> wrote:

>Carey Gregory wrote:
>
>
>Maybe, but the case I used as an example was for MI not stroke, and in
>that case there is an objective basis to justify bringing someone to a
>known cardiac facility over a community hospital.

Fine, change stroke to MI and you'll get the same story. All the hospitals
in my district also offer cardiac cath, bypass, etc. Yet there is no
established system (like there is with trauma) that allows me to justify
bypassing a closer facility, even though I certainly would with my own
family member.

>That may very well be the case in your situation, it is not in all
>others. In my county people are routinely driven to closer hospitals
>solely for the purpose of expedience, even if a facility only a little
>farther away is the better choice.

Okay, why don't you put some meat behind this statement? Your *perception*
is that it's purely for expedience. I have no idea what the reasons
actually are -- since I know probably better than you how much EMS systems
vary from one place to the next -- but you seem quite certain of yourself,
so put it on the table. How do you know this is purely for expedience?

Sharon Hope

2005-05-18, 11:41 am

On topic for wrong treatment, OT for stroke per se.

Point is that amnesia patients are typically not worked up for statins as a
potential cause, yet they are known to cause amnesia, and the most often
prescribed of all drugs world-wide, and in history.

"Dave S" <DoggtyredRN@earthlink.net> wrote in message
news:b9pge.933$r7.687@newsread1.news.pas.earthlink.net...
> Pardon me, but what does that have to do with the ACUTE treatment of an
> ischemic stroke?
>
> Dave
>
> Sharon Hope wrote:
>

Bryan

2005-05-18, 11:41 am

Carey Gregory wrote:

> Bryan <cyberbmcd@optonline.net> wrote:
>
>
>
>
> Fine, change stroke to MI and you'll get the same story. All the hospitals
> in my district also offer cardiac cath, bypass, etc. Yet there is no
> established system (like there is with trauma) that allows me to justify
> bypassing a closer facility, even though I certainly would with my own
> family member.
>

Again this is your district, not mine. The pt I referred to was brought
to a community hospital with no capability for CC that was 13 miles from
her home with all symptoms of a possible MI while the tertiary facility
whose known specialty is CC and Cardiothoracic surgery was 18 miles
away. by the EMT's own admission to the pt. he felt they should be
taking her to the our facility and not the community hospital.

>
>
>
> Okay, why don't you put some meat behind this statement? Your *perception*
> is that it's purely for expedience.

no the admission of the EMT was that it was for expedience.

I have no idea what the reasons
> actually are

I do

-- since I know probably better than you how much EMS systems
> vary from one place to the next

maybe, but obviously not in this case.

-- but you seem quite certain of yourself,

I am

> so put it on the table. How do you know this is purely for expedience?
>

answered above.

Bryan

2005-05-18, 11:41 am

HorneTD wrote:

>
> If your system allows you that latitude then fine but many do not.
> --

Well yeah, that was my point, the systems need to allow that latitude.

lenny fackler

2005-05-18, 11:41 am

HorneTD

2005-05-18, 11:41 am

Bryan

2005-05-18, 11:41 am

HorneTD

2005-05-18, 11:41 am

Larry

2005-05-18, 11:41 am

On Thu, 12 May 2005 15:39:16 -0400, Carey Gregory
<tiredofspam123@comcast.net> wrote:

>Bryan <cyberbmcd@optonline.net> wrote:
>
>Well, you really should stop it.
>
>You seem unwilling to accept the reality that in the vast majority of cases
>there is absolutely *no objective basis* on which to justify bypassing a
>closer hospital for another in cases of stroke.
>
>
>All hospitals within my coverage area offer stroke management and
>neurosurgery. Now, which ones do you think I should bypass, and on what
>basis? Sure, I know which one I'd want my relative at, but my personal
>opinion carries little weight at the department of health, and even less in
>court. Hell, even the hospitals being bypassed might file complaints once
>they learned what was happening.

Bryan, you should listen to Carey.

Allow me to add that most EMS agencies don't have a good idea of a
given hospital's specific capabilities. Hell, it's tough enough when
working in the ER to keep up with what new docs have come on board the
various services, what new equipment and techniques they're
instituting 'upstairs', and about availability of resources at various
hours of the day.

And two final points; first, to say that paramedic programs teach
'critical thinking' is laughable.

Second, medical care delivery systems should be planned, not cooked up
on the fly by whatever medic is on shift at the moment. EMS is only
one tiny portion of the greater system, and should confine it's input
to those areas where they have some expertise. Determining
in-hospital medical needs is not one of them.

Larry, EMT-P

Larry

2005-05-18, 11:41 am

On Mon, 09 May 2005 22:14:34 -0400, Bryan <cyberbmcd@optonline.net>
wrote:

>Carey Gregory wrote:
>clarification, the EMT works for a volunteer Fire Dept. with an
>ambulance crew. You can't fire a volunteer.

Who told you that?

Just because there's no paycheck doesn't mean that they can't be shown
the door.

LT

Larry

2005-05-18, 11:41 am

On Mon, 09 May 2005 23:09:21 GMT, Bob Ward <bobward@verizon.net>
wrote:

>[snip]
>More beneficial for who? The longer ride certainly makes the
>ambulance company healthier, but doesn't necessarily mean things are
>better for the patient.
>
>That''s why I think the original poster was off base - the ambulance
>is paid by the mile - they have no reason to go to the closest
>facility for expedience.

As in the rest of life, there are many competing interests at work in
a situation like this.

The local hospital wants the volume to stay alive, but so does the
larger, tertiary hospital to pay for their advanced programs.

The EMS service is best served by travelling as many 'loaded miles' as
they can, but the individual medics usually want to spend as little
time on each run as possible.

Everyone wants to provide good care, but no one wants to spend any
more than they have to in the process.

Even the patient wants the best care available for their problem, yet
really doesn't want to be involved in the situation in first place.

What happens in the end is usually a result of compromises and
resolutions of the many conflicts. If something goes wrong - absent
some obvious or glaring issue - it's tough to point at any one aspect
and single it out as the problem.

LT

outrider

2005-05-18, 11:41 am

Larry wrote:
> On Mon, 09 May 2005 23:09:21 GMT, Bob Ward <bobward@verizon.net>
> wrote:
>
>
> As in the rest of life, there are many competing interests at work in
> a situation like this.
>
> The local hospital wants the volume to stay alive, but so does the
> larger, tertiary hospital to pay for their advanced programs.
>
> The EMS service is best served by travelling as many 'loaded miles'
as
> they can, but the individual medics usually want to spend as little
> time on each run as possible.
>
> Everyone wants to provide good care, but no one wants to spend any
> more than they have to in the process.
>
> Even the patient wants the best care available for their problem, yet
> really doesn't want to be involved in the situation in first place.
>
> What happens in the end is usually a result of compromises and
> resolutions of the many conflicts. If something goes wrong - absent
> some obvious or glaring issue - it's tough to point at any one aspect
> and single it out as the problem.
>
> LT

I have been following this conversation with interest. May have missed
a bit but..

Please tell me...are the practises (and regulations) national, state,
or municipal? I assume you and Carey do not serve the same
jurisdiction, or the same jurisdiction as the OP. Yet you speak as
though there is one practise.

Here ambulances and hospitals are part of universal health care--not
for-profit. Even volunteer ambulance services would be under the
umbrella of the jurisdiction healthcare agency. An ambulance cannot
refuse anyone whether they can pay or not, cannot decide where they
will take a patient, and would be in constant contact en route by an
emerg physician in the scenario described.

Zee

HorneTD

2005-05-18, 11:41 am

Larry wrote:
> On Thu, 12 May 2005 15:39:16 -0400, Carey Gregory
> <tiredofspam123@comcast.net> wrote:
>
>
>
>
> Bryan, you should listen to Carey.
>
> Allow me to add that most EMS agencies don't have a good idea of a
> given hospital's specific capabilities. Hell, it's tough enough when
> working in the ER to keep up with what new docs have come on board the
> various services, what new equipment and techniques they're
> instituting 'upstairs', and about availability of resources at various
> hours of the day.
>
> And two final points; first, to say that paramedic programs teach
> 'critical thinking' is laughable.
>
> Second, medical care delivery systems should be planned, not cooked up
> on the fly by whatever medic is on shift at the moment. EMS is only
> one tiny portion of the greater system, and should confine it's input
> to those areas where they have some expertise. Determining
> in-hospital medical needs is not one of them.
>
> Larry, EMT-P
Now you've done it. You have contradicted he who must be believed.
He'll never let it go. For the patients arrival at a Hospital that he
believes to be improper to not be the ambulance company's fault Bryan
would have to be wrong. Now stop this foolishness and repeat after me.
Bryan is always right.
Bryan is always right.
Bryan is always right.
Bryan is always right.
Bryan is always right.
Bryan is always right.
It will be so much easier if you don't try to confuse the all knowing
Bryan with facts. Since he will never change his position that it has
to be the fault of the ambulance provider there is no reason to invest
your time in further argument.
--
Tom Horne

Carey Gregory

2005-05-18, 11:41 am

"outrider" <outrider@despammed.com> wrote:

>Please tell me...are the practises (and regulations) national, state,
>or municipal? I assume you and Carey do not serve the same
>jurisdiction, or the same jurisdiction as the OP. Yet you speak as
>though there is one practise.

The practices are municipal, county, or sometimes regional, but by no means
national. There might be some on a state level, but I'm not familiar with
them if there are.

LT and I definitely do not serve the same jurisdiction. We're in different
states.

>Here ambulances and hospitals are part of universal health care--not
>for-profit. Even volunteer ambulance services would be under the
>umbrella of the jurisdiction healthcare agency. An ambulance cannot
>refuse anyone whether they can pay or not, cannot decide where they
>will take a patient, and would be in constant contact en route by an
>emerg physician in the scenario described.

It varies in the US. I have a lot of latitude in most cases where I take a
patient (trauma being the exception), and we're not in constant contact with
a physician. We contact them as needed. However, bypassing a closer
facility has to be justifiable unless it's by patient choice. If the pt
doesn't have a preference or can't inform me of one, then they'll go to the
"nearest appropriate facility." Only with trauma do I have a clear-cut
definition of what constitutes appropriate, so at least in my jurisdiction
all serious medical patients will go to the nearest facility. Luckily, it's
a pretty good hospital, but even if it weren't, I still wouldn't have much
choice.

Bryan

2005-05-18, 11:41 am

Larry wrote:
> On Mon, 09 May 2005 22:14:34 -0400, Bryan <cyberbmcd@optonline.net>
> wrote:
>
>
>
>
> Who told you that?
>
> Just because there's no paycheck doesn't mean that they can't be shown
> the door.
>
> LT
yes, yes yes overstated for emphasis, the point wasn't the volunteer,
the point was that the volunteer should be allowed to make a choice
based on their assessment.

Bryan

2005-05-18, 11:41 am

HorneTD wrote:

> Larry wrote:
>
>
> Now you've done it. You have contradicted he who must be believed.
> He'll never let it go. For the patients arrival at a Hospital that he
> believes to be improper to not be the ambulance company's fault Bryan
> would have to be wrong. Now stop this foolishness and repeat after me.
> Bryan is always right.
> Bryan is always right.
> Bryan is always right.
> Bryan is always right.
> Bryan is always right.
> Bryan is always right.
> It will be so much easier if you don't try to confuse the all knowing
> Bryan with facts. Since he will never change his position that it has
> to be the fault of the ambulance provider there is no reason to invest
> your time in further argument.
> --
> Tom Horne
Actually sir, he made his point quite sincerely without ridiculing me or
the original poster, a case where I am much more inclined to agree with
what he said as opposed to you and your sarcasm which is quite useless
and offers no viewpoint but your own. Simply put, you are callous and
sarcastic and are guilty of what you accuse me of, that you are always
right even though I offer as many valid points as you do.

It's funny but I notice that those who believe they are always right
seem to accuse others of being guilty of the same.

look in the mirror friend.

Bryan

2005-05-18, 11:41 am

Larry wrote:

> On Thu, 12 May 2005 15:39:16 -0400, Carey Gregory
> <tiredofspam123@comcast.net> wrote:
>
>
>
>
> Bryan, you should listen to Carey.
>
> Allow me to add that most EMS agencies don't have a good idea of a
> given hospital's specific capabilities.

This seems quite silly, wouldn't the EMS system need this information to
properly do their job?

Hell, it's tough enough when
> working in the ER to keep up with what new docs have come on board the
> various services, what new equipment and techniques they're
> instituting 'upstairs', and about availability of resources at various
> hours of the day.

true, but that's more abstract than what we are talking about. this is
simply which hospital is better to take the pt having a possible MI the
known regional tertiary Medical Center that specializes in Cardiology or
the community hospital in the boondocks that happens to be 6 miles closer.

>
> And two final points; first, to say that paramedic programs teach
> 'critical thinking' is laughable.
>

I guess it depends on the program. the ones offered in my area do just
that, and quite well I might add. I have a few friends that are
paramedics and trust their judgment .

> Second, medical care delivery systems should be planned, not cooked up
> on the fly by whatever medic is on shift at the moment.

again this is not really what I was suggesting. I don't want the EMT to
set up an entire plan of care I just want him to be able to take his pt
to the facility that he believes will provide the better care to the pt
in a certain circumstance. I'm not advocating EMT's or paramedics
arguing about the merits of hospital A over hospital B in every
situation, but some cases are more cut and dried than others, and
require a bit of common sense over a set rule for all circumstances.

EMS is only
> one tiny portion of the greater system, and should confine it's input
> to those areas where they have some expertise.

right like bringing the pt. to the correct hospital that care can be
delivered at. Once again, it is not going to apply to every single
situation, but in some circumstances the EMT or Paramedic should be
allowed to overrule which hospital the pt is brought to based on the
facts at hand.

Determining
> in-hospital medical needs is not one of them.
>
> Larry, EMT-P