RE: Pt. Scenario

["Laurie A. Romig, MD" <laurie.romig@verizon.net>]

The issues of spotty ancillary service availability and specialty coverage
at nontrauma centers are definitely significant ones. It is possible, as in
Pinellas County, for EMS to keep track of what hospitals' CT scanners are
up, who has neurosurg capability, etc, with the cooperation of the hospital
community and a pretty sophisticated communications system. Such "selective
diverts" are followed closely for change in status, and field crews can call
in to our centralized medical control system for appropriate destination
selection at any time. Given, this process takes work, but I believe that it
*can* be done in a less sophisticated way than what we have the opportunity
for here in Pinellas.

The really bad news is that the specialty coverage issue is only going to
get worse, even in trauma centers. Even specialties that haven't previously
been paid for "trauma call" are demanding big bucks. More and more surgeons
are moving away from the hospital surgical setting into office and surgical
center procedures, so fewer are willing to take hospital call. In Florida,
the two hottest areas appear to be neurosurgical and hand coverage. I fear
that we'll end up losing some trauma centers if these issues aren't
addressed. (By the way, the state has appointed an Access to Care Panel to
address specialty coverage and diversion type issues and make
recommendations for legislative changes.)

Laurie Romig
Bayflite, St. Pete, FL and Pinellas County EMS
(where it's a balmy 49 degrees....Happy New Year!)

> -----Original Message-----
> From: flightmed-admin@flightweb.com
> [mailto:flightmed-admin@flightweb.com]On Behalf Of Robert Cole
> Sent: Wednesday, January 02, 2002 7:48 PM
> To: 'flightmed@flightweb.com'
> Subject: RE: Pt. Scenario
>
>
>
> good point.  Here is the flip side of things, that we just
> experienced with
> the opening of a local hospital.  This hospital can justly be called a
> community hospital, many of the staff came over from other
> hospitals, so the
> experience potential is there,  They have nice equipment, but
> they had some
> problems with a certain specialty coverage in the first few weeks,  Medics
> had to call in and ask: "Can you handle so and so type patient today?"
> Here it did  not matter because the state's trauma center is only a little
> bit down the road.  But lets say we picked up this same hospital and staff
> and moved it 50 miles north into the rural area.  What we would be faced
> with is medics (or EMT's , you know what I mean) having to make
> decisions on
> frequently changing capabilities of the hospital. Sound unlikely?
>  How many
> Hospitals only have a surgeon or CT capability during business hours, then
> they are "on call".  Same with ultrasound, and in some small
> hospitals, all
> X-ray  or even the lab techs (I've been to these hospitals!) I
> can just see
> the medic in the field trying to think..."Hmmmm, its the first
> tuesday of an
> even month...the planets are in the northern alignment...I guess our local
> medical community wants us to go to the local hospital."
> One physician mentioned, sometimes a hospital gets judged by its
> past "rep".
> He used an example of a MD sending the pt to a hospital and getting flak.
> Well sometimes the opposite happens, the EMT/Medic takes a patient to a
> hospital he Knows can provide the service the patient may
> need...and he gets
> flak.  All he did was play patient advocate, but in his mind
> "politics" got
> in the way.  now that's a definition of disillusionment.
>
> My point is this: Smaller hospitals should realize that if they
> want a real
> piece of the major trauma market, they should attempt to make them selves
> accessible in a PRACTICAL way to the trauma patient and EMS, not
> expect the
> trauma patient to work around their schedule.
> The hospital must first address the issues required to consistently treat
> these patients to a pre-determined standard (what ever the
> medical community
> decides is appropriate.) If the pt. needs higher care then the hospital
> should not "gripe".  Then the hospital must inspire confidence in
> the field
> provider. Too many docs think medic just follow protocols, never
> considering
> the patients best interest.  They must think the world of EMS is a cook
> book. Like it or not, in 80% of our calls, the patient will
> listen to us on
> serious destination decisions.  And I don't know of any medic who
> will take
> a patient to what he believes is an inappropriate hospital if he has a
> choice, no matter how pretty the nurses are.
> Robert S. "Steve" Cole
> Paramedic, CCEMTP
> Education Department
> Ada County Paramedics
> 208-375-7079
> emcolers@adaweb.net
>
> "...A mind stretched with new ideas never regains its former shape"
>
>
> -----Original Message-----
> From: John L. Meade [mailto:jmeade@statdoc.com]
> Sent: Wednesday, January 02, 2002 3:46 PM
> To: flightmed@flightweb.com
> Subject: RE: Pt. Scenario
>
>
> As an emergency physician who has practiced at trauma centers, been
> medical director of ground and air EMS services, and currently am chief
> at a mid-sized community ED, I have a perspective on this matter.
>
> I agree that egos can play a large role. However, lack of education and
> understanding of the various hospitals' capabilities on the part of EMS
> can have a major impact, as well. Quite often, people from the trauma
> center, or a flight crew, or even local EMS, don't really know what any
> given local ED or hospital can handle. When those capabilities change,
> these changes (for better or worse) are not always taken into account,
> either.
>
> For example, five years ago my current hospital had no trained emergency
> physicians, no vascular surgeons, one cardiologist, and poor coverage by
> ortho and other specialties. Now, we can handle virtually anything short
> of open heart surgery and neurosurgery. If the reputation of five years
> ago is still in people's heads, they could make a decision that is not
> appropriate for today. If one of the doctors directs EMS to do something
> that conflicts with the old reputation (but is appropriate for today),
> that doctor could be accused of doing something for ego or money, when
> that is not true.
>
> JM
>
> John L. Meade, MD, FACEP
> Chief Executive Officer
> Emerald Healthcare Group, P.A.
> Doctor's Resource Group, Inc.
> http://www.statdoc.com/
>
> "The real problem is not whether machines think, but whether men do."
> -B.F. Skinner, behavioral psychologist
>
>
>
> -----Original Message-----
> From: flightmed-admin@flightweb.com
> [mailto:flightmed-admin@flightweb.com] On Behalf Of Robert Cole
> Sent: Wednesday, January 02, 2002 16:13
> To: 'flightmed@flightweb.com'
> Subject: RE: Pt. Scenario
>
>
> good discussion all, I would mention one thing in regards to "cost" to
> the small hospitals .  Trauma is by far one of the most money losing
> patient populations when compared to other agencies.  When you look at
> the resources required for a trauma patient, the cost of personnel, OT,
> time away from other patients, etc...now look at the typical trauma
> patient is the uninsured and a major health care expense will cause them
> to declare bankruptcy...is make the expenses near unrecoverable.  I
> would think that if cost were the issue, small hospitals would love to
> send them on.  The reality (IMHO) is that Ego's play a far larger role.
> What doc (or other health care
> professional) likes to admit they are over their head? I know that as a
> medic I have trouble admitting it.  It goes contrary to what I am.  Docs
> are no different, often worse.  Its been that way since the early days
> of shock trauma.
>
> Robert S. "Steve" Cole
> Paramedic, CCEMTP
> Education Department
> Ada County Paramedics
> 208-375-7079
> emcolers@adaweb.net
>
> "...A mind stretched with new ideas never regains its former shape"
>
>
> -----Original Message-----
> From: James.J.Misuraca@Hitchcock.ORG
> [mailto:James.J.Misuraca@Hitchcock.ORG]
> Sent: Wednesday, January 02, 2002 12:00 PM
> To: flightmed@flightweb.com
> Subject: RE: Pt. Scenario
>
>
> OK lets take this one out of the realm of the flight crew. Lets pretend
> we are Dr.Joe Elemdee at the Center Barnboard Health Center. The local
> ambulance has had several of these calls this year. To his estimation,
> none of them have been as severe as they sound when they are dispatched
> or when they patch in with scene info.
> "Do I take a chance and bring them here first or do I send them 30 miles
> away to Trauma Center without ever seeing them?" As one responent
> recalled her observation of the Kansas region we struggle with these
> issues in the Vermont/ New Hampshire region. Politics, goverment,
> weather, etc.... have conspired to limit our scene response and cause us
> to struggle with this senario on nearly a daily basis. How can we make
> this sort of descion making less painful/ costly for the small
> providers? At what level of education or goverment protocol do we draw
> the line on excessive evaluation by centers that are not equiped to
> provide care? How do we do this and appear to be the "adjuncts to
> improved patient care" that we know we are versus "the money hungry
> trauma scavangers in thier expensive toy" Excuse me, devils advocate
>
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