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post #121 of 135 (permalink) Old 03-31-2009, 11:59 PM
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That would be a fair assumption: I’m an ER doc who has been in practice for 30 years and work at a Level 1 trauma center. I routinely take telemetry calls for trauma center diversions as well as consultations from outlying hospitals that lack the resources to care for these patients.
I have always said that I don't have the answers. I don't get it. But I still don't see how you, from your ER can make the call as to all the decisions PRIOR to the initial telemetry. From that point forward, I understand, from that point back, THAT is were I have the question and see too many open switches and too many remote guesses [even very educated guesses].

My main concern with your answers was that the conclusions were interwoven between facts about the specific case and general observations and opinion and dislike for the Canadian Medical system and socialized medicine in general. Those observations cloud the objectiveness of your technical opinion.

Much like when I see a financial issue go down like AIG an Treasury, I fully understand the mechanics and all the information that flows and what is both published and what is available through trending. BUT I usually caveat that with the notion that there is stuff going on of which we are unaware, elements to the puzzle that need to be present before a definitive answer can be achieved.

I talked with my ER Doc sis in law for a couple of hours this morning at the hospital about the very subject. She too is at a Level1 and a skier so this interested her greatly. Her issues were a combination of yours and mine. Questions from the before she finally saw an responder about why she was not pushed to see someone and afterwards as to what the conditions were that made the decision tree. While there is some information, is there other information that may have changed the decision.

Lots of time to talk while not looking at monitors in the Telemetry CU.

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post #122 of 135 (permalink) Old 04-01-2009, 12:30 AM
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The decision as to where to transport the patient is made at the scene not before the ambulance arrives. The EMTs assess the situation and then contact their resource hospital via telemetry as was done in this case. If I personally receive a call of this nature on the telemetry unit I would have told the EMTs to bypass the closest hospital and transfer, instead, to the nearest trauma center. The problem here, obviously, is that the nearest trauma center appeared to have been more than 1 hour drive away. Ground transport times over 30 minutes are an indication for air ambulance which was not available. That is the crux of the problem. So what are they to do? Travel long distances and risk further deterioration along the way or bring her to the closest hospital and hope she does not need neurosurgical intervention? What is their protocol for dealing with situations like that? If air ambulance were available this dilemma would not even arise.

I would be very interested to find out at what point she was intubated. Was it done in the ambulance (doubtful unless she further deteriorated during the 25 minute trip to the first hospital)? Was it done at the first ER she was taken to? Or subsequently? Because the point at which they found a need to intubate her would tell me that either she was deteriorating rapidly (bad prognostic sign) or that her GCS had fallen below 9 (ditto).

Finally don’t assume that my criticism of this case reflects in any way my feelings about "socialized medicine." I happen to believe that some sort of universal coverage is both necessary and inevitable in the U.S. We will be facing hard decisions in the very near future about the rationing of healthcare as the current trend in expenditures is simply unsustainable.
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post #123 of 135 (permalink) Old 04-01-2009, 12:47 AM
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The decision as to where to transport the patient is made at the scene not before the ambulance arrives. The EMTs assess the situation and then contact their resource hospital via telemetry as was done in this case. If I personally receive a call of this nature on the telemetry unit I would have told the EMTs to bypass the closest hospital and transfer, instead, to the nearest trauma center. The problem here, obviously, is that the nearest trauma center appeared to have been more than 1 hour drive away. Ground transport times over 30 minutes are an indication for air ambulance which was not available. That is the crux of the problem. So what are they to do? Travel long distances and risk further deterioration along the way or bring her to the closest hospital and hope she does not need neurosurgical intervention? What is their protocol for dealing with situations like that? If air ambulance were available this dilemma would not even arise.

I would be very interested to find out at what point she was intubated. Was it done in the ambulance (doubtful unless she further deteriorated during the 25 minute trip to the first hospital)? Was it done at the first ER she was taken to? Or subsequently? Because the point at which they found a need to intubate her would tell me that either she was deteriorating rapidly (bad prognostic sign) or that her GCS had fallen below 9 (ditto).

Finally don’t assume that my criticism of this case reflects in any way my feelings about "socialized medicine." I happen to believe that some sort of universal coverage is both necessary and inevitable in the U.S. We will be facing hard decisions in the very near future about the rationing of healthcare as the current trend in expenditures is simply unsustainable.
You have that part right. It will get under control, either through government intervention or collapse of its own weight.

I understand that the first transport decision. I flew a few life flights with my 182 for a few years before we got helos in Kentucky. I understand that protocol well.

The only reason we got started on this, from what I can go back and read is posts 82 and 83. They seem to deviate from the rest of your posts on the subject which are more technical in content and more to the salient points.

Part of the conversation with Bev this morning was regarding how resorts handle that here. All the resorts I have been to, and that she goes to are an easy three hours by road to a L1 center. Only states with real bucks can afford to provide sufficient helos to accommodate that kind of coverage.


Maybe that is why I wear a helmet. On the other hand, after the last experience at Breck with my somewhat metal ankle I really shouldn't be doing that any longer.

The question was asked: "How can somebody that old be that dumb?"...the response "How can somebody the dumb be that old?"

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post #124 of 135 (permalink) Old 04-01-2009, 12:52 AM Thread Starter
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Finally don’t assume that my criticism of this case reflects in any way my feelings about "socialized medicine." I happen to believe that some sort of universal coverage is both necessary and inevitable in the U.S. We will be facing hard decisions in the very near future about the rationing of healthcare as the current trend in expenditures is simply unsustainable.
Why is it unsustainable ? It's just money and Bernanke has plenty of those where they came from.

Health care spending comprises 17 percent of the GDP which is only 3 times the amount we spend eating out ! So where are our priorities ?

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post #125 of 135 (permalink) Old 04-01-2009, 12:57 AM
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To misquote Mrs Thatcher ( probably)
"The problem with Socialism is that you soon run out of other peoples money"
Our NHS is grossly overfunded, & grossly inefficient and regardless of that with ever increasing ever more expensive medical technology, no medical system however funded is able to provide limitless benefits for all, which is what Socialism appears to promise.
The only rationing system that works is finincial.
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post #126 of 135 (permalink) Old 04-01-2009, 12:27 PM
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Why is it unsustainable ? It's just money and Bernanke has plenty of those where they came from.

Health care spending comprises 17 percent of the GDP which is only 3 times the amount we spend eating out ! So where are our priorities ?

I’m not necessarily suggesting that the government run the program but I think that a basic level of coverage has to be offered to everyone perhaps by creating high risk pools that people can buy in to at an affordable rate.

And I agree with Difflock's comment, the NHS is a hot mess.
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post #127 of 135 (permalink) Old 04-01-2009, 12:52 PM
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Why is it unsustainable ? It's just money and Bernanke has plenty of those where they came from.

Health care spending comprises 17 percent of the GDP which is only 3 times the amount we spend eating out ! So where are our priorities ?
Are you suggesting we spend $1Trillion dollars a year eating out?

You might want to contact the National Restaurant Association. They will be thrilled with the sudden 2X increase in their gross sales.

And those stats include all the folks who eat 33-50% of their meals at school/work at a cafeteria. So I would assume their priority is lunch.

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post #128 of 135 (permalink) Old 04-01-2009, 01:03 PM
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I’m not necessarily suggesting that the government run the program but I think that a basic level of coverage has to be offered to everyone perhaps by creating high risk pools that people can buy in to at an affordable rate.

And I agree with Difflock's comment, the NHS is a hot mess.
I don't see it being government run in the least bit. The medicare model that my parents went through for nearly 20 years, which everyone considers a government program was fully managed by for profit commercial insurance and medical companies. From the end user stand point there were no interactions with the government.

I would imagine that on some level there would be some interface between hospital accounting departments and government or between folks like BlueCross and Government.

So if you extrapolate that sub-system, tune up the process to reduce inefficiencies there is no reason to assume that model can't be scaled up.

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post #129 of 135 (permalink) Old 04-01-2009, 02:10 PM Thread Starter
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I’m not necessarily suggesting that the government run the program but I think that a basic level of coverage has to be offered to everyone perhaps by creating high risk pools that people can buy in to at an affordable rate.

And I agree with Difflock's comment, the NHS is a hot mess.
Offering voluntary mandatory coverage will lead to the "sign up for insurance only after you get sick" problem.

The government can do a lot more in attacking the supply side of the problem by funding medical schools , training medical personnel, building hospitals with the trillions of dollars it is creating right now. There are plenty of smart kids every year who would like to get into the medical profession but are rejected due to limited training facilities.
That should lower health care costs in the long run.
All I hear now is squeezing costs out of the soon to be called evil insurance , pharma, medical industries.
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post #130 of 135 (permalink) Old 04-01-2009, 02:14 PM Thread Starter
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Are you suggesting we spend $1Trillion dollars a year eating out?

You might want to contact the National Restaurant Association. They will be thrilled with the sudden 2X increase in their gross sales.

And those stats include all the folks who eat 33-50% of their meals at school/work at a cafeteria. So I would assume their priority is lunch.
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