First of all, know the location of every hospital in the surrounding area. Know which ones are teaching hospitals, which ones are certified Trauma centers, and which one (if any) specializes in strokes. If the person you are caregiver for has a primary care physician learn which hospital he/she has priviliges at. The chances are, if that hospital is not nearby an ambulance may not take your loved one there.
Make sure the house number is displayed and if in apartment building there is a number on the door.
In an complicated apartment complex it helps to have someone meet them downstairs, if an extra person is available.
Call 911. If there is no ambulance in ten minutes call back. In certain areas you can by-pass 911 and save time by calling the fire dispatcher directly if you know the number. Ask at your local firehouse.
Usually you will find them uninterested in speaking with your own physician on the telephone. They have their protocols, and in an emergency this only wastes time.
Municipal ambulances generally have to go to the closest appropriate hospital in the event of a life-threatening emergency. There are exceptions. During busy times the dispatcher may tell them "So-and-so Hospital is on diversion". That means the ER is full and the hospital is not accepting new patients.
At night, you have a better chance of having them divert to a hospital a little ways further because traffic is thin and they can make better time.
Secondly, learn what emergency ambulance services are available. In some jurisdictions there are only volunteers, In others private ambulances under contract (Randal-Eastern in Miami, for example). In other cities there may be a mix of municipal ambulances and those from what are called proprietaries - private hospitals with their own services.
It pays to have a notarized medical proxy for your loved one. Otherwise you may find when the ambulances goes to the hospital they may will not talk to you. They usually do, but not always.
If the patient is a veteran have their veterans's ID card taped to their bed. It pays to tell the VA you have "lost one" and get a duplicate. Otherwise, if a VA card is not available, the ambulance won't go to a Veteran's Hospital Emergency room. This can have catastrophic financial consequences. Some (but not all) veterans are eligible for one hundred percent free care and prescriptions. But only at VA facilities. Until recently they were not required to have other insurance (which in any case may have a deductable). In New York, for example, NYU Medical Center has an emergency room adjacent to the VA. NYU is under contract to run the VA ER. Thus, the same physicians work in both ER's. However, if a veteran does not have an ID card the ambulance may transport to NYU. Suddenly you will end up with a bill that may run into several thousand dollars.
Have the patient's insurance cards available next to the bed and make sure the aide knows where they are.
If the patient is stroke-disabled and has difficulty communicating use the dry-erase board and bring it along in the ambulance.
The ambulance crew wants to talk to the patient and hear the problem "in the patients own words". Not by hearsay.
Don't be offended if they ask you to be quiet while they do this.
A patient is entitled to be transported in a carry chair from their residence to an ambulance and then lie down on a cot. They are NOT supposed to be told to "sit on the bench". Violations of this protocol are the norm, rather than the exception.
Try to get the names or shield numbers of the ambulance crew, and the ambulance dispatch call number.
If your loved one is being handled on a routine transport (say from a nursing home to another home), do not allow them to use the siren, violate traffic laws, or run red lights. This is common with private ambulances. Common is not the word. It represents the norm.
If you have a wheel chair (especially a personally purchased one), make sure the name, address and telephone contact number is on the back in prominent letters. Otherwise it will get lost at the hospital.. If there is an aide on duty at the home, make it part of her job to ask that the wheelchair be brought along.
You are entitled to ride in the back with your loved one. Often, the EMT or paramedic will tell you "Follow in your care - insurance doesn't permit you to ride". This is a load of nonsense. A fiction. If the situation is critical you are entitled to hold your loved-ones hand during what may be their last moments. Be polite, but firm. Use any means short of a physical threat to ride in back. Generally only one person is allowed to ride alone (it does get cramped), but again exceptions are made.
If this is the case, and you are riding along, and the situation looks bad, remember the following suggestion:
There a few ambulance "rackets" that come up from time to time. The private hospitals, called proprietaries, often bribe EMT's and paramedics to deliver patients to their hospital when the patient has insurance and dump patients that are obviously uninsured or homeless in municipal hospitals. They do this by offering free meals, stethascopes, free bandage scissors, and sometimes tickets to baseball or football games to ambulance crews that bring in the most patients. Hospitals are, believe it or not money-making institutions.
Another misdeed is when a municipal ambulance shows up, hesitstes to transport, and recommends a private ambulance because the hospital you want to go to is "too far". The paramedic just happens to have a card in his/her wallet and makes the call for you. Later on there is a cash kickback. Oftimes this company is one for which the EMT/Paramedic works part-time.
Tipping is something that will come in your mind. The municipal ambulances are staffed by very adequately paid crews and should not be tipped. If they do an especially good job you might offer a small sum (no more than five bucks) to "buy you and your partner a cup of coffee.
Private ambulance crews, on the other hand, are often paid the minimum wage, and if the trip is especially long, and a non-emergency, a ten dollar tip after the job would not be out of order.
In the case of volunteer crews, send a contribution to their headquarters.
This is a small cloth bag with handles marked in magic marker with the patient's name and phone number and address.
1. A lot depends upon whether the elderly person is alone when the 911 call is made or a caregiver is present. It is best to prepare two single-sheets of paper and have them laminated. These should contain information on all medications, chronic illnesses, the number of the primary care physician and EMERGENCY FAMILY CONTACTS with work and home telephone numbers.. A patient in distress and low on oxygen will become confused and may not be able to supply these details. I am not a fan of keeping this information in a vial in the refrigerator.
2. One sheet is taped to the bed. The second duplicate sheet goes into a cloth "ready bag" left on a doorknob.
3. The "ready-bag" contains a brand new toothbrush, comb, hard case for eyeglasses, hard case for dentures, hard case for hearing aide, wrapped bar of soap, and a brand new pair of panties or underwear and a brand new pair of white diabetic socks. If the patient is incontinent, a new diaper. If admitted, for some reason there never seems to be a toothbrush or comb available for a day or so. Hearing aides are expensive, and easily lost in a hospital.
4. Hospitals have ample supplies of insulin for diabetics, but they usually won't provide thyroid meds until they get labs, so this medication should be in the bag. Also an albuterol sulfate emergency inhaler. No vitamins. The reason is that hospitals now routinely heparinize patients to prevent clots and the vitamin K in multi-vitamins inactivates the heparin.
5. Cell phone and charger.
6. Five to ten dollars in quarters. If admitted these will be handy for the hospital vending machines.
The EMT's and paramedics will lock the door but five times out of ten they forget to give you the keys back. Have a duplicate set available to someone.
When you call 911 the dispatcher will "triage" the call. This will affect the qualifications of the ambulance crew and the equipment on board. You will be assigned either a "BLS", or basic life-support ambulance or an "ALS" of advanced life support ambulance. Furthermore, sick calls will be answered after cardiac calls. A "sick" may wait two hours while a "difficulty breather" will get an eight minute response.
If you have to wait a while ask the dispatcher if they are in "backlog". If so, ask how long before you can expect an ambulance. In ninety-nine percent of the cases it is worth waiting. If you arrive by ambulance you will usually go to the head of the line in respect to the triage nurse. It isn't supposed to be this way, but it is.
This discussion brings us to the so-called "DNR" or "Do Not resuscitate" form. There is indeed a place and time to "die with dignity", but it is fact that in some hospitals these forms are "sold" to every patient over seventy, including those in decent health, like ice-cream cones on a 120 degree summer day.
I have been preswhen a physician told a perfectly healthy 80 year old "You don't want to have your ribs broken by CPR or under painful electrical shocks of several thousand volts..."
At that point I needed blood pressure control medication.
If a patient is clearly near the end of life, especially if they are in extreme pain, or a terminal cancer patient, a DNR is indeed appropriate. Otherwise, I would think twice.
Case in point. A patient had an irregular heartbeat. He/she is in an ambulance on a monitor. Suddenly the monitor changes to ventricular fibrillation.
The probability of converting V-fib with a rhythym compatable with life varies directly with the time to induce electrical counterhock. If you cath this rhythym within the first 15030 seconds this can be done quite simply by what is called the "pre-cordial thump". The EMT takes his fist into a hammer position six inches above the sternum and slams it down on the chest. "Poof." The rhythm reverts to normal sinus. This isn't a myth. It was taught at one time as part of CPR. I have done this four times. No CPR. No endotracheal intubation.
If you have waved a DNR around, the EMT/paramedic does ungotz - NOTHING.
If you mention DNR to the dispatcher count on getting a BLS ambulance and going to the end of the triahe line.
Let's take another case. The patient has chest pain and weakness in an arm and one side of the face. She is having a stroke. Daughter is there when the ambulance arrives and waves the "DNR" chicken in the crew's face. They go into zombie mode. Instead of a line and siren run to the nearest stroke center, they deposit mom at a nearby private hospital without a neurologist on duty. Mom comes home three days later, partially paralyzed permanently and blind in one eye.
Or mom has an asthmatic attack. Paramedics are often trained in endotracheal intubation. They arrive and son waves the DNR chicken in their faces. They do not intubate. Mom dies quite unnecessarily.
The DNR, no matter what hospitals say, is interpreted quite differently by some nineteen year old EMT who shows up at the house.
Now let's address what are called "bedpan transfers". These are from a nursing home to a nursing home, a hospital to another hospital, or hospital to a rehab facility. These are normally relegated to private ambulance companies, which invariably grossly overcharge for services. One reason is that is no competition. Licenses to operate ambulances are normally granted by politicians only after showing "a certificate of necessaity". This artificially grandfathers in old companies, precluded new entries, and the licenses are traded like New York City Taxi Medalions. It also manages to ensure a shortfall of ambulaces in time of a disaster. When a friendly hospital tells you "I'll arrange the transfer" it invariably means a kickback to someone. You may think this doesn't matter because "insurance pays", but there is often a co-pay. Recently a friend was released from hip replacement to a rehab facility two hours away. The ambulance transfer bill was $1,400. He had a twenty-percent co-pay. He could have engaged any private car service to do the job and been transported in a stretch limousine with bar service for $200. You might ask why car services don't dip into this lucrative business. Well, the ambulance companies have them charged with operating an ambulance without licensure. But you can engage a car service on your own. And arrange with a private ambulance on your own. And you will always get a lower rate by doing so.
The privates often have "paramedic ambulance" on the sides and bill for "paramedics" when instead of two paramedics for get a non-certified driver and an EMT.
Bedpan transfers on private ambulances are invariably performed at high speed, often on the wrong side of the road, siren and lights on, red lights be darned. This is called the "siren-and-red-light-syndrome", common amongst EMT's and it deserves a special place on the DSM (which categorizes mental disorders) Do not permit this.
My solution, after a spectucular crash involving one of these privates while running a red light on a routine transfer, was to go into a hospital parking lot with an electric sawzall and cut the cables to the Class Sixty Federal Sirens on four private ambulances while the crews were inside servicing clients.
On the other hand ambulances that handle true 911 emergencies definitely have a need for and should use both sirens and emergency warning lights.
In terms of hospital transfers one of the biggest issues is that hospitals will not leave an intravenous line in place. There are various reasons for this. When lines had to be serviced with a "KVO" line of D5W there was a need for a professional to be with the patient. Nowadays hospitals use what is called a "heplock" which doesn't require an open line to a source of fluid. Nevertheless, these lines are routinely removed. Discuss this and ask if a nurse or medic accompanies the patient can the line be left in place. The super elderly often have a limited supply of veins and you will blow a precious medial antecubital line installed an hour ago for the sake of "insurance" purposes.
What is always appreciated, if a crew, either private or municipal provides over-the-top respect and service is to write a letter of commendation to their company or superior or Chief of fire services. People who do good work never get enough thank-you's.
Finally we come to the problem of "mom won't go to the hospital".
This requires psychology.
If you are an EMT or paramedic you have to become a stage actor and go through a monologue. Basically, you tell them "My boss will suspend me if I don't take you, and I have a wife and six kids to take care of..." A variant of this speech is suitable for health care aides. "You wouldn't want to cause me all that trouble?"
If you are at home and get a call from an EMT at mom's house, ask them to do this.
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