“Oh yes, doctor. That is so much better! You see, Billy is so ugly that we couldn’t possibly have put a picture of his face in the yearbook! This picture of his ribcage is much more appealing! Thank you so much!”
Billy: “Yeah, wait until the guys get a load of my widened mediastinum! That’ll show them!”
It looks like they had three-dimensional chest x-rays back then!
If x-rays were that good, even I, one of the radiologically challenged, would be able to read them!
Trust me, if I can see something wrong on your x-ray, you are really sick!
Ambulance diversion.Does it really help emergency department overload?
In the counties I have worked, the emergency departments are allowed to go on “ambulance diversion” status.
This means that anytime the ED cannot safely handle any additional patients, based on specific criteria, they are able to divert ambulance traffic to other area hospitals.
That “specific criteria” usually means one of two things:
- You have no monitoring capabilities as you have every monitor tied up with a patient who requires it.
- You ED has maxed out its resources and cannot safely handle another patient. For example, your ED has monitors available, but you have three critical patients in cardiogenic shock and all available staff are required to care for these patients until they can be transferred to the unit.
Lack of staff and/or lack of critical care beds are not, for example, criteria for diverting ambulance traffic.
The status of any particular ED is visible on a county-wide monitoring system; a computer resides in each ED.
(You can also signal the county if your CT scanner is down: patients with head injuries and possible strokes will automatically be diverted.)
Some counties have restrictions on how many hours you are allowed to be on divert in a 24 hour period, some have limits on how many consecutive hours are allowed.
Others have no restrictions, but keep track of the different hospitals and evaluate how much time they spend on diversion.
Too much time on diversion is a no-no.
But what exactly does it accomplish?
- Well, it might keep elderly, altered and septic patients from nursing homes from arriving by ambulance.
- It will keep the ambulance-for-the-stubbed-toe folks from arriving.
And that is about it.
- If you are in cardiac arrest, you go to the nearest hospital, period! Diversion means nothing at this point. Even if you don’t have a monitor and have to perform resuscitation in the hallway, that patient is coming and you will find the means to deal with it.
- If the paramedics are going Code 3 (red lights and siren) they will come to your hospital. You don’t question the medic’s decision – it is their call. And it should be. You must accept Code 3 traffic at all times. It means the patient is critical.
- On both sides of the San Francisco Bay, there are hospitals 5-15 minutes apart all down the highways. If two hospitals in a row are on diversion, then neither of them are on diversion, because it would mean passing up two hospitals for care.
- Diversion does not stop:
- the walk in MIs
- the patients with pulmonary edema
- the decompensating asthmatics
- the suicidal overdoses
- the trauma patients laying in the back of their friend’s truck
- the patient with the CVA whose family managed to get them into the car despite the paralysis of their entire left side.
You get the picture. In addition:
- Patients who have an HMO plan and are transported to non-HMO hospitals because of diversion have to deal with extra paperwork to make sure their hospitalization is covered or have to deal with the extra trauma of being transferred for admission to the hospital that was diverting at the time of their call to EMS.
- Some hospitals in our area are well known for certain specialties and patients often request facilities for that reason; requests that cannot be accomodated if the facility is on divert.
- A patient may be diverted to a facility where their regular doctor does not have admitting privledges, especially distressing if the doctor was planning on meeting the patient at their usual hosptial.
Some of my worst shifts have resulted not from ambulance traffic, but by the acuity and number of walk-in patients to the department.
So while it may be psychologically comforting (and it is) to think that you will not be receiving ambulance traffic, diversion can cause distress to patients, put pressure on the medics in the field and you can never really be sure that the Code 3 ring-down isn’t just a second away.
Ambulance diversion just gives the illusion of control, something that you never get in emergency departments.
It’s the nature of the beast.