Let's Analyze This

A couple days I ago I discussed the problem with complaining about the job – and how I didn’t want to turn this blog into one long whine session about nursing homes, dispatchers, and only extremely occasionally triage nurses – that troika of fienddom.* I want to be able to write about the paramedic’s axis of evil* in a way that is not petty whining, so I will try to write this in a way that tries to examine the system rather than the individual because it is always the system that puts the individual in place to be the system's face.

Here’s the scenario:

The nursing home has a patient who for the last five days been more lethargic than usual. Her labs taken two days ago show her white blood cells, nuetrofills, BUN and Creatine are elevated. The nursing home nurse is aware of her nursing home’s policy that requires nurses to call 911 for all nonscheduled visits to the hospital, i.e. –the emergency department where the doctor wants the patient evaluated. She dials 911 and tells the police dispatcher she has a non-emergency routine transport to the ER.

He tells her to call the commercial ambulance service. She does.

Eleven minutes later the commercial ambulance service calls the police dispatcher and says they have received a priority one call from the nursing home that they are compelled to transfer to the town’s 911 provider because it is a priority emergency. The priority is for the lethargic patient.

We are then sent lights and sirens along with a police car for the lethargic patient.

We go charging into the nursing home and they want to know who we are there for. Do we have a patient name? No, we’re sent for the emergency. You have a lethargic patient? We don’t have any emergencies here, they say.

Eventually we find the patient. A lady who is not lethargic and in no pain or distress. She just feels tired. We take her to the hospital.

Down at the hospital we see her Doctor – Doctor Miles. He has so many nursing home patients, they are have earned (from some) the collective and unfortunate name “Miles’ Reptiles.” No Joke.

Now how does this happen that a nursing home calls a 911 emergency line for a non-emergency, says it’s not an emergency, the police department tells them to call a commercial service (that is being offered a money making transport -- the reason they are in business), and then somehow the commercial service kicks the nonemergency call back to the town transforming it to an emergency in the process and then the town police dispatcher tells the town ambulance to go lights and sirens to the same nursing home call they have already directly been told is not an emergency?

Let’s analyze this:

#1. Why can’t the doctor see the nonemergency patient in the nursing home?

He’s too busy. Let the ambulances bring his patients to him. Fair enough, I guess. To his credit I have seen him at nursing homes before. Still, sometimes I wonder.

#2 Why does the nursing home call 911 for nonemergency calls?

Complicated answer. An attorney general ruling several years ago ruled that emergency calls needed to go to the town’s 911 service and not a commercial service, then some bureaucrat lawyer went on to define what an emergency call was and it included just about anything causing distress or pain that was unscheduled.

What followed was chaos with volunteer services being besieged with nursing home transfers that had previously gone to commercials. The town where I work saw its volume increase by 25% in one year.

While the town service was doing the transfer, someone in the town would get in a bad car wreck and the closest ambulance had to come all the way out from the city to get there, while everyone cried “Where is the ambulance?”

The state finally reacted by writing a letter to the nursing homes telling them they could use their discretion in defining whether a call was an emergency or a medical transport, calling 911 for the emergency and the commercial for the transport. So just because a patient was in pain from a five day old fall didn’t mean they had to call 911.

Somehow this nursing home never got the updated memo. Or if they did, their lawyer told them to be safe call 911 for everyone.

#3 How does a commercial ambulance turn a non-emergency into an emergency?

When calls come in to their dispatch center, they are EMDed (Emergency Medical Dispatched) meaning the caller is asked a number of questions based on an algorithm, the answers determine how the ambulance is dispatched. EMD's backers claim the EMD system is medically sound. It seems to not allow the call taker much leeway, probably for legal reasons. We are often sent lights and sirens based simply on a patient's history or based on a caller's choice of words, when a more in depth interviw would reveal severe bleeding is no more than a small cut on a finger, that the cardiac patient's fall was a trip not a dizzy spell, that the lethargy is minor and has been going on for five days.

Is the blame on the algorithm the call takers use? Did the word “lethargic”automatically trigger the priority one response? Or did the individual call-taker just have no sense and completely disregard the nurse's statement that it was not an emergency? '

I have no problem going lights and sirens only to find out there is no emergency when I get there, but when you can easily determine that there is no life and death emergency over the phone, don't send an ambulance and police cars or fire engines lights and sirens. We always say it -- "Someday someone is going to get killed." Imagine if the ambulance going emergency to the above described non-emergency crashed, causing a real emergency. You are talking serious liability.

I ask these questions everyday because the same scenarios seem to occur everyday. They happen to me. They happen to everyone working the streets.

I am not complaining about doing the call or the workload. I am on both sides of this because I work for the commercial early in the week and the town 911 service later in the week. So I either do or don’t do the call depending where I am. I just want the system to get it right.

***

The second call is for a violent psych. Here’s how it goes down:

Another nursing home in town calls the commercial ambulance for the psych. The commercial passes the call to the town as a violent psych. The town sends us lights and sirens along with a pistol-packing Kevlar-vested handcuffs on the belt police officer for muscle.

We find a blind sixty-year-old woman sleeping in a chair. We wake her up and have to help her to the stretcher because she walks so poorly on her own.

The nurse says the patient threatened to scratch the nurse, thus earning the “violent” label from the call-taker. (“Violent” of course signals the need for police presence. Remember Scene Safety comes first.)

The patient says she has no desire to hurt anyone one.

We take her to the hospital. I will note I have transported her on other occasions for the same offense. (I am worried this may be three strikes and she’s out for her. Instead of residing at the convalescent home, she may end up shackled to the wall at the Institute for the Criminally Insane up on the mountain.

People following well-intentioned policies cause strange things to happen.

***

We also did a seizure. It wasn't me seizing, though I felt I was about to convulse several times.


* The trioka of fienddom and the paramedic's axis of evil --nursing homes, dispatchers, and sometimes triage nurses -- these flashing danger zones are where the medic has his main interaction and possibility for unpleasant skirmishing. I mention triage nurses mainly jokingly as I have great respect for 99% of them.