Apple #471: From Ambulance to Hospital

Regular Daily Apple readers know that I've been having some trouble with my ears following a scuba diving class.  Don't worry, this is not why I'm doing an entry about ambulance services.  I went to the doctor about the ear thing yesterday, and he gave me some prescriptions.  They've had no effect so far other than to make me really speedy, but it's only been one day so I'm going to give it a little more time.

No, the reason for this entry is because of a question that came up in conversation a little while ago.  A group of us were talking about a news article I'd seen around the 4th of July, which reported that a guy named Eric had blown off his arm while shooting off fireworks.  They weren't your average grocery store fireworks, but commercial-grade mortars he was lighting from a three-foot metal tube.  One of them, after he'd lit it, shot out of the tube and hit him in his left arm and blew it off.


A rack of tubes designed to hold fireworks mortars.  Harry, the guy who works for Skylighter, the company that makes these mortar racks, says, "When using this rack, I drill holes in the feet and drive spikes through them and into the ground to keep the rack from bouncing and falling over. Care must be taken to avoid driving fasteners into the mortars. In pyro this is known as a 'bad-thing.'"
(Photo from Skylighter)



Fireworks mortars can be pretty huge. These are sold by Fireworks by Spectrum in Pennsylvania.


Eric's friends wrapped his arm in ice and got him and the arm to the hospital.  Unfortunately, it sounds like he lost his arm permanently:

While she wouldn't comment on the status of Smith's arm, spokeswoman Shelley Lotenburg said the hospital does not perform limb reattachments.

After many exclamations like "Dude, that would suck, getting your arm to the hospital and it turns out they can't put it on!" we wondered whether he'd been brought to a different hospital, if his arm could have been reattached.  (Actually, a different news article reported that his friends said his arm from the shoulder to the elbow had been "blown to bits," so maybe not.)

This discussion then led us to a larger question, which none of us knew the answer to, which was, when you're being driven to the hospital in an ambulance, who decides which hospital you get taken to?


Paramedics in Folsom, California.
(Photo from the City of Folsom)

• First of all, the people in the ambulance are EMTs.  That stands for Emergency Medical Technician.  There are different levels of EMT, depending on how much training they've had.

• Basic EMTs (EMT-1s) are trained for about 120-150 hours in basic life support.  They can assess what's going on, bandage bleeding wounds, and provide basic medications like oxygen, glucose, aspirin, asthma inhalants, or epinephrine.  They can't give shots or IVs.

• Intermediate EMTs (EMT-Is) get an additional 50 or so hours of training.  They can give shots and start IVs and depending on which part of the country they're in, they may also be trained in assessing cardiac situations and providing appropriate medication, as well as some level of airway management like clearing an obstruction or intubating.

• Paramedics are EMTs who have gotten even more extensive training.  They receive ten times the amount of training as basic EMTs and have often gotten degrees from two-year programs.  Paramedics can give shots and start IVs, they are allowed to use a lot more types of medications than the EMT-Is, they can handle lots of different airway management situations, they can read EKGs, and they might even be certified to suture wounds.

Paramedics in training. They're learning how to intubate, provide oxygen, and use IVs.
(Photo from the Emergency and Investigative Educational Institute in Florida)

• So the people in the ambulance will all be at least a Basic EMT.  Probably the driver is a Basic EMT.  The people working in the back of the bus might be EMT-Is or paramedics.

Driver compartment of an ambulance in New Jersey.
(Photo from Roseland First Aid Squad)

• Ambulances themselves are given different classifications.  Some provide Basic Life Support (BLS).  Some are equipped for Advanced Life Support (ALS).  

• All ALS ambulances are staffed only with paramedics.  It used to be that most ambulances were BLS class, but it looks like more communities are getting only ALS ambulances.

The interior of a 2004 Ford F-350 ALS ambulance in Arizona.
(Photo from Christopher Kohl's Volunteer Fire Department)

• Ambulances can vary in other ways, too.  Who owns and operates ambulances can vary from state to state, county to county, and city to city.  Most ambulances are part of local fire departments.  Some ambulances are part of an integrated police-fire-emergency medical response department.  Occasionally ambulances are owned and operated by hospitals or by private medical companies. These hospitals and companies work closely with local fire departments and emergency dispatchers. 

Interior of a 2008 ALS ambulance owned by the Red Cross in Austria.
(Photo by ggrexy on Flickr)

• Regardless, the people inside the ambulance are trained in life support, they know how to assess the severity of a wound or a medical situation, and they are familiar with the hospital services in the area.

• If you are alert when you're put into an ambulance, you could tell them, "Please take me to such & such hospital, I don't trust the doctors anyplace else," or "My insurance only covers me at thus & so hospital."  Or a family member could say something to that effect.  If possible, they'll do as you request.

• But there are a lot of factors that go into the decision about which hospital they'll take you to.  Some of those factors might trump your wishes, in which case they'd take you to a different hospital.

Interior of an ambulance in New Jersey
(Photo from Roseland First Aid Squad)

• Here's what's involved in deciding what hospital to go to:

• Which is closest. Even if the nearest hospital may be across county or state lines, most ambulances are allowed to bring patients to whichever is closest.

• Type of medical need, and which hospital treats those situations. For example, serious trauma patients need to be treated at Level 1 Trauma Centers, but not every hospital has such a center.  Not every hospital has a pediatrics unit or an OB/GYN unit either, which means not every hospital will accept a woman in labor.

• Hospital availability.  Occasionally, a hospital may send out an alert that they can't accept more patients.  Their beds are full, some crucial equipment is not working, or they don't have enough staff on hand.  When that happens, a bulletin goes out to the dispatchers and the ambulances so they'll know not to take people to that hospital.

• Patient request. Especially if the patient's request is based on insurance coverage, or previous history with a hospital or medical personnel at a given location, this will play a fairly big role in the decision.

• Police custody. If a patient is in police custody, the police can dictate where the patient has to be taken.

• Here's one dramatic example of when the nearest hospital isn't always best. A guy named Chuck who'd had a stroke when he was out mountain climbing had a helicopter ambulance come out to get him.  The pilot wanted to take him to the nearest hospital, but the paramedic and the nurse on board said no, take him to this other hospital 15 miles farther away because they have a certified stroke center.  They stood there yelling at the pilot until he agreed to take Chuck to the other hospital.  When he got there, the hospital with the stroke center gave him a specific medication that dissolved the clot in his brain, saving his life.  The nearer hospital probably wouldn't have had that medication on hand.

The interior of a helicopter ambulance. This one is the AW139, and it's in use in the US, the UK, and Italy.
(Photo from aerospace-technology.com)

• In general, where an ambulance takes a patient is a judgment call and there's some flexibility in the decision-making process.  

• Based on some chat room conversations among EMTs, it sounds like those who work for hospitals or private companies, as opposed to local governments, are told to give the patients' wishes a higher level of priority -- which can be frustrating to the EMTs.

Because I'm curious about things inside of ambulances, here's an EMT trauma kit. It contains an array of bandages, scissors, ointments, cold compresses, gloves, and other essentials. That cylinder toward the back contains oxygen. The whole thing weighs 24 pounds.
(Photo and EMT O2 trauma case from Biotek)

• One last fact.  It's difficult to get total data on the number of ambulance trips made for the entire country.  But I can tell you that the total number of ambulance trips in 2001 that were billed to Medicare -- which is certainly not all of them --  topped 10 million.

Sources
NY man blows off arm with fireworks, CNN.com, July 4, 2010
Man who lost arm lighting fireworks in stable condition, WABC, July 5, 2010
AlliedHealthWorld, EMT and Paramedic, EMT and Paramedic FAQs
Rod Brouhard, About.com: First Aid, The Difference Between an EMT and a Paramedic
Bureau of Labor Statistics, Emergency Medical Technicians and Paramedics
Wikipedia, Paramedic
emtcity.com, It is the patient's choice right?
Wanakee Area EMS FAQs
Hopper Institute, EMS Calls
Sierra-Sacramento Valley EMS Agency, ALS Program Policy
Salt Lake City EMS District Hospitals, Hospital Diversion Protocol 
Poudre Valley Health System, Ambulance Services
Crozer-Keystone Health System, Springfield Hospital EMS
Elizabeth Cohen, Picking the right hospital can save your life, CNN, July 26, 2007
GAO, Ambulance Services: Medicare Payments Can Be Better Targeted to Trips in Less Densely Populated Areas, September 2003