1. #1
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    Default On scene time for private ambulance

    My department has some issues with the care provided by our private ambulance service. Just wanted to see if this is isolated to our area or if its a new trend.

    1. On scene times - privates are doing almost ALL care on scene, after the patient is in the ambulance it is regular practice for the medic to render all care on scene and then transport. My crew times the ambulances and average 8 minutes sitting in the ambulance, times have been over 20 minutes.... the hospital is less than 10 minutes away from any part of town.

    2. 12 leads- Our first responder ALS protocols do not have 12 lead in them and our monitors are not 12 lead capable. However the private medics now rely on them and withhold care to do them. In addition their "12 lead" comes back NSR almost every time. They are now doing them on almost every abd pain, chest pain, S.O.B. my unconfirmed theory is the company has an unwritten policy so they can bill for 12 lead on most patients. I don't understand the 12 lead, it doesn't change patient care for a positive and the doctors rarely even look at it and if they do they still order one at the hospital right away. It goes back to the treat the patient not the monitor saying..... maybe I am just an EMS dinosaur.

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    Quote Originally Posted by Blacklab View Post
    1. On scene times - privates are doing almost ALL care on scene, after the patient is in the ambulance it is regular practice for the medic to render all care on scene and then transport. My crew times the ambulances and average 8 minutes sitting in the ambulance, times have been over 20 minutes.... the hospital is less than 10 minutes away from any part of town.
    Most good medics that I know will concentrate on finding and ruling out things that can be corrected or helped by the medic. I don't think that 8 minutes in the back of an ambulance is unreasonable to initiate routine ALS and give a quick exam. IV, monitor, O2, 12-lead, bG level check, etc. Remember that this is the only time that this patient will have an advanced level care provider dedicated to him or her. When they get to the hospital the doctor or nurse will most likely be splitting their time with other patients.

    Working on a patient in the back of a moving ambulance is a rediculously dangerous practice for routine patients. If a patient needs an IV med or a nebulizer setup, do it on scene, stablize the patient, sit your *** in a seat, and then start to transport. Why should I risk a a serious injury if I'm in an accident because I was squatting next to the patient to start an IV rather than sitting in the captain's chair?

    Quote Originally Posted by Blacklab View Post
    2. 12 leads- Our first responder ALS protocols do not have 12 lead in them and our monitors are not 12 lead capable. However the private medics now rely on them and withhold care to do them. In addition their "12 lead" comes back NSR almost every time. They are now doing them on almost every abd pain, chest pain, S.O.B. my unconfirmed theory is the company has an unwritten policy so they can bill for 12 lead on most patients. I don't understand the 12 lead, it doesn't change patient care for a positive and the doctors rarely even look at it and if they do they still order one at the hospital right away. It goes back to the treat the patient not the monitor saying..... maybe I am just an EMS dinosaur.
    Pre hospital 12 leads are the standard of care for ACS patients. Study after study proves that a reduced door-to-balloon time in a cath lab dramatically improves the outcome of the patient. If a STEMI patient can be identified by a paramedic while on scene then the hospital can be better prepared to accept and treat this patient. Prehospital oxygen and a nitro can also change a patient's 12 lead. If a 12 lead is obtained by the paramedic immediately after or even before NTG is given then acute changes can be appreciated by a cardiologist and the patient's long term outcome can be dramatically improved.

    Remember also that heart attack patients have a variety of symptoms. Female and diabetic patients often present with no pain in their chest, but other nonspecific complaints such as shortness of breath, lightheadedness, and abdominal pain. Doing a 12 lead on patients of this nature is completely acceptable.

    You're theory as to the private company billing for a 12 lead isn't a good theory. Medicare and the majority of private insurance carriers pays for the level of service given to the patient, not for how much the paramedic does. An abdominal patient that gets three lead monitoring, O2, and IV gets billed the same way as a chest pain patient that gets a 12 lead, O2, IV, Aspirin, Nitro, and Morphine.

    Sorry to ramble.

    - Turk

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    I worked as a private medic for 5 years, started every IV with the exception of a few in a moving ambulance and never got hurt or came close to getting hurt. I also consider myself a very good medic but I know what I am, a security guard of medicine. By that I mean medics don't cure people, we stabilize long enough to get the patient to definitive care. The most dangerous medics on the street are the ones that think our job is to cure people.

    A good medic should be able to start IVs contact base and do their assessment within 5 -10 minutes, which is also the transport time around here so there is no reason to sit. If you want to start IVs in the safest stationary place then go work as an ER tech.

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    BTW there is a flat fee for level of care, there are also additional fees for equipment and procedures done....I used to review billing.

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    Quote Originally Posted by Blacklab View Post
    1. On scene times - privates are doing almost ALL care on scene, after the patient is in the ambulance it is regular practice for the medic to render all care on scene and then transport. My crew times the ambulances and average 8 minutes sitting in the ambulance, times have been over 20 minutes.... the hospital is less than 10 minutes away from any part of town.
    You get your IV, O2, monitor, and depending on the pt condition, and complaints, additional interventions. You are going to look pretty silly if you CP pt goes to shiit because you didnt do something. CYA.

    Quote Originally Posted by Blacklab View Post
    2. 12 leads- Our first responder ALS protocols do not have 12 lead in them and our monitors are not 12 lead capable. However the private medics now rely on them and withhold care to do them. In addition their "12 lead" comes back NSR almost every time. They are now doing them on almost every abd pain, chest pain, S.O.B. my unconfirmed theory is the company has an unwritten policy so they can bill for 12 lead on most patients. I don't understand the 12 lead, it doesn't change patient care for a positive and the doctors rarely even look at it and if they do they still order one at the hospital right away. It goes back to the treat the patient not the monitor saying..... maybe I am just an EMS dinosaur.
    Hows does one "withhold care" to do a 12 lead?
    I do a 12 lead on anyone c/o CP, or upper abdominal pn. Seeing if there is elevation or depression in any leads, ESPECIALLY the ST segments is indictive of an MI. You can also see if there is a RV Infarct, which administering nitro to would serve to only excerbate the condition.
    I don't know about your docs, but we can issue a STEMI Alert, and transport to the appropiate facility. All the repeat 12 lead does is double check our Dx, and it can further determine the course of a pts tx.
    AJ, MICP, FireMedic
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    This message has been made longer, in part from a grant from the You Are a Freaking Moron Foundation.

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    BLS,

    Sorry for the delay in reply but I need a moderator to read my posts prior to them showing up.


    I am not advocating doing no care, I am advocating doing care on the way to the hospital. You will also look pretty bad if your patient crumps on scene while you sat there 10 minutes doing care, 5 minutes from the hospital.

    As far as the 12 lead withholding care. My point is that if there is a cardiac patient presenting then why do a 12 lead instead of intervention? If it can be done while getting things set up then fine, but I would never withhold NTG, MS, ASA for a 12 lead....EVER. The 12 lead is great for determining silent MI, or for determining that a problem presenting such as ABD pain may be cardiac. But this goes back to treat the patient not the monitor. Its like a pulse ox, would you put 12 LPM on a patient with good skin signs, normal lung sounds and respiratory rate if they had a pulse ox of 70? I would hope not. But would you put one on a patient with crappy symptoms and a pulse ox of 98? I would hope so.

    In addition every intern I have had has had to start IVs en route. There are plenty of red lights and stop signs to start IVs at if you need to stop. Our job is to get them to the hospital. I have watched two calls where a new school 12 lead, do everything on scene medic had a patient die in their bus. Both times I know it wouldn't have happened to me, I would have been at the hospital, with IV, and meds on board writing my paperwork when they coded....that is if they coded. Maybe a doctor would have seen something I didn't, maybe meds I don't carry would have been on board. Lets not build up our egos and what we do too much. If the ambulance runs out of fuel idling on scene then we're a failure no matter how many 12 leads and IVs we do.

    Not saying everything has to be done en route, but I am sure it is inappropriate to do everything on scene.

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    Quote Originally Posted by Blacklab View Post
    My department has some issues with the care provided by our private ambulance service. Just wanted to see if this is isolated to our area or if its a new trend.

    1. On scene times - privates are doing almost ALL care on scene, after the patient is in the ambulance it is regular practice for the medic to render all care on scene and then transport. My crew times the ambulances and average 8 minutes sitting in the ambulance, times have been over 20 minutes.... the hospital is less than 10 minutes away from any part of town.

    I think that is too long, but why are you staying? I offer my crew's assistance once we get them in the ambulance, and if they decline we leave. Our services our no longer wanted / needed. No reason to hang out. If they need a driver or something that is different, but once we get the guy in the ambulance on 99% of the calls we leave.

    2. 12 leads- Our first responder ALS protocols do not have 12 lead in them and our monitors are not 12 lead capable. However the private medics now rely on them and withhold care to do them. In addition their "12 lead" comes back NSR almost every time. They are now doing them on almost every abd pain, chest pain, S.O.B. my unconfirmed theory is the company has an unwritten policy so they can bill for 12 lead on most patients. I don't understand the 12 lead, it doesn't change patient care for a positive and the doctors rarely even look at it and if they do they still order one at the hospital right away. It goes back to the treat the patient not the monitor saying..... maybe I am just an EMS dinosaur.
    I think the 12 Leads have a benefit, but a 12 Lead doesn't really increase the bill if they are starting an IV. By simply doing a 12 Lead they are not able to charge more, in most cases that procedure will not raise the charge from an ALS1 to an ALS2.

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    What they said. If I didn't do a 12 lead here, if the call indicated it, it would be considered a protocol violation unless I document mitigating circumstances. Our doctors here look at our 12 leads, can't speak for everywhere. Here we activate the cath lab from the field for STEMI and go right pass ED triage to the lab. So, doing a 12 lead is speeding up care rather than withholding it. Besides, if you know what you're doing, it doesn't take much longer to put on a 12 lead than a regular 3-4 lead. Also, sometimes it can take the first 10 minutes on scene just to get the pt. into the back of the ambulance! Again, if the pt is stable, it's not really that big a deal. The whole reason for the development and expansion of ALS was to bring care to the pt. Now unstable/critical pts., yes...we should not be dallying on scene. But taking a few extra minutes on scene with a stable pt., especially if the hospital is close is completely reasonable. Especially since it's quite possible that their care may be delayed upon arriving at the ED. EDs are busy these days! If you haven't adequately assessed the patient and begun treatment/access, then you'll look awfully stupid when you deposit your pt. on a hallway bed with no assessment. That defeats the purpose of bringing paramedic care to the field. Also, this is not a private vs public issue. Most places here are fire-based and the same standard practices exist. I'm aware of some of the places that have issues with privates but it's unfair to intimate that this has anything to do with private vs public and billing.
    Last edited by mtngael; 03-20-2008 at 11:02 AM.

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