We Gave an Inch, They Took a Mile

by Clayton Kazan, MD MS

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EMS Physicians need to be drivers of the EMS system and recognize that we are a Mobile Community Healthcare Provider and not providing medical direction to a fleet of glorified Ubers.  This seems like a total “no-brainer,” yet we find ourselves grappling with problems like Ambulance Patient Offload Delay (APOD, aka Ambulance Wall Time) that we should never have allowed to happen.  If, in your system, APOD is not a problem, then I suggest you stop reading this and migrate over to your Facebook account because you must be the Medical Director of the Shangri-La EMS system.  For those of you who share my system’s difficulties, I am going to blow your mind…we often blame the hospitals for APOD, but the fault lies with us because we depended on the hospitals to fix a problem that they have little incentive to address.  Meanwhile, despite the fact that EMTALA gives us firm legal ground to hold hospitals accountable, our inaction on the issue has led the problem to fester to the point of ridiculousness. 

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EMTALA is quite clear about who bears responsibility for patients that present to Emergency Departments.  The 250 yard rule has always been a bit difficult for me to understand, especially when it means that my ER is responsible for a “patient” in the Burger King Drive-Thru across the street.  Regardless, there is no question that a patient belongs to the hospital the minute the ambulance wheels stop.  So, the ambulance enters the ER doors, passes through the gauntlet of parked ambulance gurneys  a volley of offcolor remarks from our inebriates, and vomiting in stereo from our flu patients, and our patient finds their way to the triage nurse.  With the state of ED’s these days, it would be laughably unrealistic to expect them to have a space for our patient, but when did this become an EMS problem?  Our shared experience is that the triage nurse, in true pirate captain form, shanghais the ambulance crew and sentences them to hours on the wall as unpaid members of the ED staff.  Part of this comes from a mistaken belief by some that the patient remains the responsibility of the EMS crew until such a time as the ED is ready to accept the patient, and part of this is sheer desperation at paralyzed ED and hospital throughput.  But, again, when did this become an EMS problem?  If the EMS call volume was ever too high, would it be OK for us to kidnap 2 ER nurses and put them on an ambulance?  Why is the opposite any more reasonable or palatable?  Is this a game of chicken with the hospitals to see how long our crews will wait on the wall until we direct them to start leaving?

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None of this speaks to the ethics of a formalized handoff of patient care.  I certainly understand the importance of providing critical care, and I recognize that sometimes ED’s need a few minutes to rein in their chaos.  I do not suggest that ambulance patients be placed on luggage carousels in the ambulance bay to be claimed inside (or not), but the kindness and patience of EMS crews has clearly been taken advantage of.  EMS and ED work is a team sport, but the ED has become a Kobe Bryant-like teammate, that takes all the shots and glares at any dissent.  When did 10-15 minutes of acceptable waiting become 4 hours?  When did the priorities of the ED outweigh the importance of insuring that someone shows up when communities dial 911?  Perhaps the root of the problem lies in our background as hospital workers and our sympathy to the ED. 

So, I cannot raise a problem without proposing a solution.  The answer truly is fixing hospital throughput, and I spent 4 years on various hospital committees championing just that, with uninspiring results.  How about if the hospitals hire their own EMTs to hold the wall with these patients…the standard of care is the same, but, at least the hospital bears the cost and the community gets its ambulance back.  The hospital can carve roast beef in the ambulance bay if it wants to, but their overcrowding and failure to address their throughput issues really isn’t an EMS problem.  Until we hold the hospitals’ feet to the fire, they have no incentive to fix the problem. 

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So, when people ask you how much APOD time is acceptable, the answer is zero.  This is a hospital problem that demands a hospital solution.  We wait out of courtesy and support for our ED partners, but our patience is wearing thin.  The day we start walking out when our clock runs out or when it hits the hospital’s pocket book is the day the hospitals will engage.

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