Hacker News Reader

So many good questions/points. Responding to each: 1. This would be an ideal world, but it just isn't the case. Nor do I think its a feasible solution to train nursing home nurses to be as knowledgeable about pathophysiology as physicians. Subtleties of acute cardiac syndrome (heart attacks, etc) are difficult to recognize, and it takes a few years of residency after medical school to be able to quickly recognize and act on them. There are many great nurses that can too, but that usually comes with lots of experience in critical situations (especially in the ICU, ER, and PACU). Nursing home nurses just don't have the same exposure to critically ill patients. 2. Which county? Those are great times. A word of caution when interpreting response times - they often start the clock at the time of dispatch, not the time of the patient calling 911. A lot of Call9's value is cutting out the inefficiencies between the 911 call and the dispatch. 3. Administering aspirin (ASA) is very significant. Anti-platelet therapy (e.g. aspirin) has been shown to decrease the mortality of heart attack patients significantly, and the earlier you give the aspirin, the sooner it works. As for nitroglycerin ('nitro'), the medication that dilates the blood vessels on the hearts surface and allows for better oxygen delivery to heart muscle as its dying in a heart attack, it is extremely dangerous to self administer nitro in certain situations that can only be interpreted if you have an EKG - in one of our patients, we in fact identified this issue and purposefully held the nurses giving off this medication which could have killed the patient. As for the nursing home, this situation happened in, the nurses are well trained and I've been happy with their level of care and concern for their patients. 4. I too think a proactive response makes sense. Good point about the utility of these diagnostics - we surely have cases where they are useful in facilitating the care of patient in an emergency. But they are extremely useful in preventing unnecessary hospitalizations - another key value of Call9. In this way, we do practice urgent care too. . Thanks for your comments - seems like you've been in the field and know your stuff.

Thanks for the thoughtful reply!

I agree, the ideal world and the real world are two very different things. Though still, given the length of your average RN course (or even LPN, since as we're talking real world, many nursing facilities are supervised by one RN over many LPNs) versus EMT... certainly it "should" be better. You do make a very good point about the nature of chronic versus acute patients.

2. Thurston (http://www.co.thurston.wa.us/medic1/stats.htm) - I'm not entirely sure about the measurement of response time, would have to clarify with a dispatchers.

3. Thank you for calling out this. Agreed, ASA is very significant, and should not be discounted. I meant that emergently it's not going to improve patient condition, but I should have acknowledged that's only one part of the treatment plan. NTG, too, at least here, is typically administered or assisted by BLS with numerous contra-indications (brady/tachycardia, hypotension, etc), but most patients I have seen are instructed by their physician to self-administer with symptoms "similar to previous cardiac event". I'm presuming right ventricular infarction on your example patient?

As said elsewhere, I would like to see a service like this succeed, and apologize if I come off 'skeptical' in some of my comments!

This whole thread looks like tempest in a teapot. They provide emergency physicians on call for nursing homes (and maybe other facilities) that already have nurses and other healthcare providers in them. So any analogy to 911 is beside the point.

Their 911 claims (and the people who attack them on HN) - all this could easily be just viral marketing. :)

I worked 911 in NYC and LA. The incompetence of Nursing Home Staff is often quite astounding.

It was common to arrive for a call of "general illness" only to find the patient in respiratory failure or cardiac arrest with no CPR in progress.

I see this as providing a fast way for clueless staff to up-triage patients.

Yeah. Anything that can be done to limit the damage of "ignorance and/or incompetence" is always a good thing.

My pet hate is always "Do you have a history on the patient or what's been going on?" was almost invariably answered with:

a) "No, this is my first day", or

b) "No, I just got on shift"

Oh. Good.

Telemedicine can potentially add value in many settings, like here http://nyti.ms/1fyWXeK. What I disagree with is their misleading marketing as an alternative to 911.

For regular people, this service is like a family doctor visit on Skype. Sometimes it can be handy, but it remains to be seen how this impacts outcomes statistically. (I wouldn't use this myself.)

For healthcare facilities, like nursing homes, this is like providing a doctor on call via telemedicine. Many hospitals already do this with radiologists or neurologists for example.

What is misleading is their marketing jump from these potentially useful scenarios to advertising as an alternative to 911 for the general public, and even claiming that they are faster than 911 when in fact they are a gatekeeper to 911.

While not wanting to paint with too broad a brush, many nursing/assisted living facilities have as a first priority the avoidance or at least dilution of liability. For example, in one facility, the management, the building owner, and the nursing provider will likely be three separate business entities. I can easily imagine that "call 911" is start and end of their approach to emergencies. If the patient dies, well there are probably 10 more people on the waitlist for that room.

Absolutely. I saw this time and time again. Things that were done to minimize liability, rather than patient's best interest - and that should never be acceptable. The least reason of which is financial, but people and their families are paying four, sometimes five digits a month for places whereby anything more than taking vitals is handled by 'do nothing, call 911', all the while charging for 'round the clock nursing care'.

Ditto. 15 mins response times are old statistics.

"Since the 1970s, arriving within eight minutes 90% of the time has been the gold standard for determining the quality of an EMS system."

"NFPA 1710 states that first responders and BLS units must arrive on scene within a four-minute timeframe 90% of the time for all incidents. The ALS crew that must respond within eight minutes."

Source: http://www.jems.com/articles/2012/02/great-ambulance-respons...

Look their own sales pitch in the article is the death knell for this startup.

Protocol with 911:

* Person has suspected heart attack symptoms.

* 911 is called, short triage on the phone.

* Ambulance is dispatched.

Protocol with this new startup:

* Person has suspected heart attack symptoms.

* Skype with doctor, short triage on Skype.

* Doctor quickly trains nurse (conveniently available on site) to take EKG (presumably while patient is grasping his chest).

* Nurse takes first EKG in her life.

* Doctor reads EKG, and calls 911.

Who in their right mind would call a gatekeeper instead of 911 in an emergency?

If I may clarify some of the misunderstandings of what happens in a typical emergency. If a patient is clutching their chest, we're calling our ambulance service, not doing an EKG. However, the great majority of heart attacks don't present with crushing chest pain. If they did, Emergency Care would be easy, and EM docs wouldn't have had to do 11 years of schooling to recognize and treat these subtleties. The patient that the TechCrunch article is referring too had a subtle tachypnea (slightly elevated respiratory rate because the dying heart muscle causes the blood to become acidic and so the body compensates by blowing off Co2) and a vague abdominal discomfort with a lot of confounding factors like constipation. This patient would not get an EKG in the overwhelming majority of nursing homes in the country, and it's not their fault! It's just because the system doesn't allow for the evaluation the patient may need. Also - an EKG is quite easy to do - this is a non-issue.

Hi, this is Jessica from Call9. Just wanted to address a few points here:

1) When you call 911, you talk to a gatekeeper. That gatekeeper is a phone dispatcher, not a doctor. Talking to a doctor is not a delay in care--it's the reason people call 911 in the first place.

2) Since Call9 works with facilities such as nursing homes and has access to patient information, using Call9 actually saves time in the dispatch process.

3) As described in the article, it's not always that clear to the person calling 911 has "suspected heart attack symptoms". In the given example, he presented with abdominal pain. That is why having the doctor be the first point of contact is so important.

"Since Call9 works with facilities such as nursing homes and has access to patient information, using Call9 actually saves time in the dispatch process."

Wait. The facility shares PHI (protected health information) with Call9? Have the facility residents consented to this?

Yes

If this information is provided and accurate, this is awesome. I love it. :)

Too much time is taken while care providers ask each other vague questions about "do you know what he/she has?" when in my head I'm thinking "You should KNOW this. Or have it readily available!"

Your doctor is a gatekeeper to 911, so you have an additional gatekeeper. I think you will find that anyone in the general public experiencing an emergency is going to call 911, not your service.

Your service might be useful in non-emergencies. It's basically like a family doctor visit on Skype. There are a number of companies offering this, but it's not clear how this helps with outcomes. (For example, http://nyti.ms/1fyWXeK)

For healthcare facilities, like nursing homes, you are basically providing a doctor on call via telemedicine. That is already heavily used. Many hospitals employ radiologists, neurologists, etc who can view diagnostic images and data remotely and provide consultation to the medical staff on site.

What I think is dishonest (and could cost lives) is advertising your service to the general public as an alternative to 911, and especially claiming that it is faster than 911.

These are interesting points. I think that it’s important to clarify a major differentiating factor between Call9 and other telemedicine providers: not only do we have an ER doctor directly interfacing with the patient immediately, but we also have on-site healthcare staff who are prepared to perform diagnostic tests and immediate medical interventions under a doctor’s direction. This is different than a consult where a doctor can only virtually advise, but cannot intervene; it is also different that calling a doctor for a specialty consult or a second opinion.

It is true that putting a doctor first in the process adds another step before calling 911. But it is a meaningful interaction that improves the quality and efficiency of the medical care (both by having an ER doctor assess the patient, and by having information ready so that the 911 call can go faster). It’s not about cutting out steps, but reorganizing the system to optimize care and save lives.

I think it might be helpful as we are discussing this to be able to explain how the current 911 system works.

As it exists now, calling 911 for an ambulance sets off a chain of 9 human-to-human information transfers and averages over an hour for you to get to the hospital and be treated by a doctor. Many articles and research papers are out there showing the inefficiencies of the current system.

Current 911 system STEP 1: You call 911

STEP 2: Cellular service carrier connects you to an operator (4.5% busy signal rate)

STEP 3: Operator with no medical background takes your basic information and location

STEP 4: Operator types that info into a processing/relay system

STEP 5: EMS Dispatcher reads the relayed info

STEP 6: EMS Dispatcher radios paramedics to go to scene [Steps 1-6: average of 3.9 mins]

STEP 7: Paramedics type address into dashboard GPS system

STEP 8: Paramedics drive to scene [Step 7-8: average of 9 mins]

STEP 9: Paramedics treat, stabilize, and package you

STEP 10: If advanced procedure or medication is needed, paramedic must call a designated physician in a local emergency department to gain approval.

STEP 11: Nurse or other employee answers phone and then finds a physician who is concurrently taking care of other patients in the ER

STEP 12: ER doctor hears your case from the paramedics

STEP 13: ER doctor approves advanced procedures or asks for clarifying information [Step 9-13: average of 14.9 mins]

STEP 14: Paramedic transfers you to the hospital

STEP 15: Paramedics drop you off at an ER (may not be the same ER who approved the advanced procedure) [Step 14-15: average 12.2 mins]

STEP 16a (CRITICAL): In critical situation, paramedic with 2 years of training and no access to your medical records tells what they know about your case to an ER physician STEP 16b (URGENT/EMERGENT): In noncritical situation, paramedic tells the ER triage nurse about your case

STEP 17: ER triage nurse tells the treating nurse assigned to you about your case

STEP 18: Treating nurse tells an MD about your case

STEP 19: You wait for an MD [Step 15-19: average 24 mins]

STEP 20: An MD finally sees you

As physicians who worked in the emergency departments of the world’s leading medical institutions we were able to see first hand the inefficiencies of the current emergency care system leading to poor patient outcomes and avoidable costs.

TLDR - 1) 911 is an outdated system in many ways 2) there is room for improvement.

This is an overly 'exaggerated' flowchart. Whilst there are many flaws with the 911 system, there are also several fallacies (though not universal):

STEP 2: <1% busy signal is a goal of and attained by a large number of PSAPs.

3: Many PSAPs have their dispatchers trained to the EMT level.

4 through 6 are happening concurrently, not as a single step flow.

6: Many PSAPs have a goal that the initial unit dispatch is within 60 seconds of call reception.

7: I've not seen a system yet that relies on ALS units punching an address manually into a TomTom. AVLS (automatic vehicle location system), and mobile data terminals pull the exact information that is entered into 911 (which whilst still prone to error, is an issue with Call9, too) and use GPS which is linked into maps + county GIS overlays.

8: Highly dependent on location. My county has an average 6min response time.

10: Most advanced procedures and medications are governed by offline medical control ("here's our protocol for using this drug / treatment. Indications, contraindications, dosing regime") - the goal is that the need to contact a physician is the exception, not the rule.

If the time taken for 'online medical control' is 14.9 minutes I'll be at the hospital already, because that's where definitive care happens. I, as a medic, am not going to wait on hold and have a leisurely chat with a physician for nearly quarter of an hour on scene. This is a gross distortion of reality. If I do need to call the ER doc, there will be one available, or the charge nurse will know that one needs to be found, now.

16a: at an SNF if we need access to medical records, we can get them. If a patient uses the same healthcare system, they're available at the hospital. Pretending like we're stabbing in the dark and shrugging our shoulders is devaluing the care that paramedics and EMTs do down to the 'ambulance driver' stereotype. Both are trained in patient assessment and history taking, even if not medically qualified to the same level as a physician. In 16b: In a non-critical situation AND there are insufficient resources, then triage is the most appropriate care situation. If you're non-emergent and there's capacity in the ED you're going to a bed.

17/18: As opposed to... what? Unless Call9 claims to be the sole definitive (and remote) care provided, there's going to be a transfer of knowledge.

Your example has it taking a quarter of an hour to get to the patient, an undefined amount of time treating, stabilizing and packaging the patient, supposedly before requiring an online sign-off and discussion with a physician lasting another quarter of an hour before finally loading the patient for another nearly quarter hour trip to the hospital, while some paramedic with no situational awareness gives a nurse a hand off to relay to the physician.

What really happens on scene in a cardiac arrest: BLS providers show up first, AED, CPR, bag patient, potentially with advanced airway, LMA, etc. ALS shows up, determines quickly whether to stabilize on scene or load-and-go, CPR still in progress. A call is made to the hospital, with no discussion with a physician, only the charge, giving pertinent information, and ETA.

"Code Blue, Ambulance, Bed A3, 4 minutes out."

RT, IV, pharmacy, imaging, are all ready. A team is ready to continue CPR. Physician is there. All staff with the exception of the physician move patient from gurney to bed, begin work, while physician gets information from ALS, and then begins directing the code.

You seem to know your stuff and work in a great system. . There's a lot here in these comments, and I'll do my best to sum up my thoughts succinctly:

We've done A LOT of user research including days of time on the back of ambulances, days of sitting in nursing homes and watching how a typical 911 call (not a Call9 call) works, countless conversations and late nights with world-leading experts in EMS care, and years of being an EM doc on the receiving end. . Paramedics are NOT just ambulance drivers. They are some of the most valuable members of our society (and surely undervalued/underpaid). But THE reason I left my job to pursue Call9 with my team, is because I have felt if only a trained EM doc could have been in the field, than many of my patients with unfortunate outcomes could have decreased morbidity/mortality. With Call9, we can do that, and save patients who are not otherwise being saved.

Even if exaggerated, his flow is closer than yours for our area in terms of delay. The last accident with a family member of mine had very competent ambulance and team get to use within 5-10 minutes. I got to the hospital and registered before they arrived without speeding. There was another long delay before she was in a room with nurses talking to her. Several got the same information. The overall difference between "event is happening" and "a doctor is seeing her" was in the 30min-1hr range. If it was more serious, the consequences of delays might have been more serious.

So, you and your team seem to be very competent with no tolerance for BS that endangers those you care for. But be careful not to project what you do onto the whole system. The system varies in efficiency, how much people care, steps in between, and so on. A whole spectrum. An outfit like yours might have less need for this service but I've experienced many that could use it.

That doesn't even count the whole "help less competent people in a nursing home assess a potentially, deadly situation" part. I'm totally with them on that.

I think you're confused or just being overly cynical. The process, as described, is exactly like traditional 911, but your first point of contact is a physician who can, if needed, immediately dispatch an ambulance (just like in your first scenario). If deemed appropriate (by a emergency physician trained to deal with life threatening situations), an EKG can be requested and the nurse can be guided through the process. If I'm in an emergency medical situation, I would absolutely want to connect with an emergency physician first and I'm sure there are many other people who feel the same way.