When the Right Decision Might Seem Wrong

When the Right Decision Might Seem Wrong

Oct 17, 2019

The world of social media is full of experts on almost every topic, including prehospital medical care.  When I say experts, I guess I should really be saying “experts.”  There are a lot of people out there who know how we should perform our jobs, and how things should be done.  Let’s take a closer look at one such example that recently made its way on to my timeline.

You’re a BLS provider.  A 70 year old male who is experiencing chest pain calls 911.  The patient and his wife tell you that he has a history of an MI which was treated in Philadelphia in the year prior.  They are requesting to go to a community hospital without interventional cardiac catheterization capabilities that is about 20 minutes away.  About 15 minutes past the community hospital is a larger hospital with an interventional cath lab.  The paramedics are on the way, and you have an opportunity to meet them on the highway.  The safest place to rendezvous with them is at a rest area just after you get on the highway.

You pull over, and wait for the paramedics to arrive.  The wait is described as causing as long as a “15 minute delay” to perform a 12-lead EKG.  The EKG is done, it comes back as non-diagnostic for STEMI, and the transport to the community hospital is completed.  At the surface, with the theatrics of a storyteller aside, as an “expert” on EMS, it seems appropriate to me.  There was a decision to be made and a determination of what definitive care was for that patient.  If he was positive for a STEMI, an interventional cath lab becomes definitive care, not a community hospital without those capabilities.

A husband and wife residing in Sea Isle City, New Jersey disagree with my view.  They felt the care was inappropriate and the delay was not warranted.  They took their concerns to the town council.

Barbara Crowley told the city council that “If this delay had been the last time, I would have lost my husband.”  I can play the “what if” game too.  If this delay had happened last time, the patient would have had ALS level care by his side.  He would have been transported to a hospital capable of caring for his presentation, most likely negating the need for an expensive helicopter ride to Philadelphia.  If the delay had not occurred this time and he was, in fact, having another heart attack, he might not have survived his trip and stay at the smaller community hospital.

Even a councilwoman, who states she is a nurse said, “I’m saying, as a nurse, just get them to the hospital. Don’t stop along the side of the road.”  Sorry, ma’am.  You are wrong.

The name of the game these days is no longer “door to balloon” time.  Its “First medical contact (FMC) to balloon” time.  The medical community is finally including the EMS portion of a patient’s care in their metrics.  Time is muscle, and a decision involving taking a patient to a facility that is better capable of caring for them might cost minutes now, but it could save an hour or more later.

It is a conversation that many of us have on a daily basis.  People want to go to a specific hospital that lacks a specialty that their current medical condition requires.  Whether it’s a trauma center, a stroke center, a hospital with pediatric capabilities. . . the list goes on and on.  It is up to us as the experts in these situations, and the advocates for our patients, to help them make the best-informed decision possible.  Regardless of where their “medical records” might reside.

From reading the Facebook comments, another question comes to mind: how did the department handle this complaint when it was brought to their attention?  How much education was given to the family?

A few years ago, I wrote about an almost identical scenario that took place in Indiana where a patient who was reported as “sick” had too long of a transport time to the hospital.  Much like the Crowley’s complaint in Sea Isle City, the allegations were largely based on the “what if?” game.  In that article, I said, “This is a prime example of why we need more EMS focused (Public Information Officers).  Once again, we have failed to put ourselves out there and let people know what we do.”  This is a scenario that repeats itself over and over again.  We take our position in the community for granted.  We fail to educate the public of our actual capabilities and the processes we follow.

The bottom line though is some people are never going to be happy, no matter how much we try to appease them.  Hopefully the town decides to stand behind the EMTs and their decision regardless of the view point shared by one of their own council people.