by FireBeyond | 2025-05-22 01:27:28+00:00
As a paramedic, I need to comment on some of these, while acknowledging that there are absolutely shitty situations and I can understand your frustration:

> In my experience, every effort is made at every level to unfailingly recommend a hospital visit at every opportune moment, regardless of the underlying medical necessities.

> Being conscious and responsive, the EMTs will determine I'm stable, and then the $64,000 question: "Do You Want To Go To The Hospital?" and all you need to say is "no".

There are legal aspects to this. As a paramedic, I am not a physician. I don't have access to much in the way of diagnostic imaging (very few, but more, ambulances are getting ultrasound) nor do I have labs, nor did I go to medical school.

The question I asked (and taught the EMT and paramedic students I have taught) is "What do you want to see happen here today?". "Do you want to go to the hospital?" far more often is replied to with "I don't know, that's why I called, what do you think I should do?". Really, often the answer is more around "I want to know I'm not in any immediate danger". I can explain to the patient what we did and considered, and give them that perspective.

> Once I visited a mini-clinic in a pharmacy. Not Urgent Care, no emergent condition, just a clinic visit with a nurse to check my BP. After reading my BP the nurse informed me she was duty-bound to contact 9-1-1.

Hypotension without access to knowledge of your history of same can absolutely be a medical emergency. I love EMTs, but they also only have bare medical training (160-200 hours), and they are very much trained to "err on the side of caution" - the rationale is that it's better to send 10 people to hospital for heartburn than it is to advise the patient having upper abdominal pain to stay at home and see if they feel better the next day when they are actually having an undiagnosed MI.

> I've been at Urgent Care telemedicine visits and if I admit to the wrong symptom they will immediately shut down the call and refer me directly to E.R.

Telemedicine can't (really) see you, has only the grossest visual cues to assess sickness (in EMS, "sick" means needs a hospital, urgently, and "not sick" doesn't mean not sick, just less acute). If you say you're feeling weak or dizzy and they can't assess vitals, of course they're going to refer you somewhere that can do those things, and not just truck along with "oh well, let's do the best we can".

> I was once signing admission papers to a BH hospital. I was conscious and responsive and arguably quite sane. The papers had a series of agreements which included one blanket consent to transfer me to any other facility they pleased.

Hospitals are largely only set up for psychiatric stabilization (leaving aside for now your statement), and honestly, generally, pretty poorly. Varying facilities have different ability to cope with patients who may be psychotic, physically violent, or otherwise, symptoms that may not be immediately apparent. Note that regular hospital admission paperwork will also have blanket consent to transfer you to a facility better equipped to care for you if they cannot.

> Often, I would say that LTC and palliative care facilities may not have staff equipped to determine necessity for going to the hospital. If they have an issue with a resident and they don't know what it is, or they're feeling over their head, they're going to just punt to 9-1-1 and let the hospital figure it out on their end

Sadly, I absolutely and utterly agree with you on this statement. I have gone to far too many 911 calls where the chief complaint is "patient/caregiver personality conflict", not an acute medical issue. However I'd argue that the hospital isn't trying to "find something". They want you out of the ER and back home (even at its most cynical - you sitting in an ER bed while they run some tests but everyone knows there's no real issue, is a bed that can't be used for someone acutely ill, who will, for better or worse, generate more income).

> Every time I read about someone lamenting how medical "care" was denied by insurance, I simply consider how many medically unnecessary propositions have been placed before me, and I needed to be the voice of reason, to shut those down, before I was exploited and viewed as a cash cow to slip claims past the insurance company.

The issue with this is sometimes to make you be the voice of reason, and have autonomy. Like near the top of my reply, "Do I need to go to hospital?" "Well, I've assessed your heart rhythm. Your vitals look within normal limits. I've done X, Y, Z. That means [blah]. What I haven't done and I can't know is A B and C, and that can only be done at a hospital." and then I can say "In my opinion you need to be at a hospital, for these reasons", or "I don't see an immediate need. You can follow up with your PCP, urgent care, or you can absolutely call us back if things deteriorate."

Which all comes down to quality of care provided. The system is ... fucked. EMTs making barely minimum wage often running 24 or even 48 hour shifts... SNFs tend to (often, not always) attract the lower tier of nursing provider quality. And then we throw in health insurers (and it's not even insurance in almost any definition of the word[1]) and healthcare.

[1] By which I mean, map health insurance to auto insurance: Your car gets totaled. Your insurer says, "Hey, we're going to pay out $25K for your vehicle. You have a $1,000 deductible, so that's us down to $24,000, and then your copay for a total loss is $2,000, so that brings us to $22,000. For total losses, your coinsurance 'as your contribution for your vehicle coverage' is 20%, which is $5,000, so here's your check, $17,000. But that's only if you're buying a Hyundai, otherwise the vehicle is out of network and you'll get a check for $8,500 instead."