# bls transport refusing a patient



## xsullyx (Mar 29, 2010)

wanted to see what you guys think about this.

the other day i was working as a transport bls unit. we do get emergency calls from time to time and thus was one of them.
we get on scene to find an 84 yo male cc: hypotension pt is conscious but unoriented with grabled speech. nursing home says he has been "in and out of it all day" current vitals were bp 66/40 pulse: 50 irreg eyes: constrict sluggish
skin cool pale dry. equal adeq pms function in extemities no facial droop

nursing home took vitals 2 HOURS before our arrival and put hom in front of their desk while waiting to ems. due to his low bp, irreg heart rate, and lack of assessable orientations/pain we chose to refuse the call and pass it to als. 
well this made a few nurses very upset. we made them clear the difference between als/bls and that, even tho the pt is till moving (kinda) it might be better for him to go with someobe who can monitor and shovk if necessary (no aeds on bls transport trucks in pa... yet)

the nurses then got real nice and sweet and even offered to put the pt on our stretcher and wheel him down to the truck... we called med command to confirm and gave the call to als

question i have is: our bosses ( the owners) got real pissy like when we calle in our als request. has anyone else had to contend with workplace tension because they chose to follow protocol or made a desicion based on pt needs?

ps. in pa als is inicated for ( in regards to this scene)
    bp <90 sys pulse <60 
pps typed on iphone srry for spell/grammar lol


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## JPINFV (Mar 29, 2010)

Nope... never had a problem at my old place with requesting paramedics. Of course requesting paramedics was easy. Pick up the phone, call 911, advise 911 dispatcher that this was a BLS crew. I never advised the nursing staff that I was requesting paramedics until I was on the phone with the 911 operator. 

Something to remember, though. If transport time to the closest hospital is less than the paramedic response time, then just transport unless you don't have enough providers on scene to provide care (i.e. cardiac arrest).


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## Flight-LP (Mar 29, 2010)

Were these abnormal vital signs passed on at the time of call? How long did ALS take? What would have been your transport time to the ER?


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## xsullyx (Mar 29, 2010)

those vitals were taken when i assessed the pt on scene. als to this location is awesome with no lie <3 min response time. for us to get him to the hospital lights and sirens estimated 10-15 mins. with Als so close and this guy having the lowest bp ive ever seen ( in my whopping 6 months on the job lol) i chose to standby


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## Flight-LP (Mar 29, 2010)

xsullyx said:


> those vitals were taken when i assessed the pt on scene. als to this location is awesome with no lie <3 min response time. for us to get him to the hospital lights and sirens estimated 10-15 mins. with Als so close and this guy having the lowest bp ive ever seen ( in my whopping 6 months on the job lol) i chose to standby



Seems reasonable.


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## bstone (Mar 29, 2010)

Here is a path of less resistance- move the PT into your ambulance, call for ALS. The NH will never know.


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## JPINFV (Mar 29, 2010)

I see a few issues with that. 

1. Since the main location I worked accessed paramedics through the 911 system, a lot of times calling on scene is easier. To be honest, a lot of times I'm at nursing homes I know I'm at X nursing home (especially if I know how to get there on memory alone), not 123 Any Way, This Town, Na 12345. Enhanced 911 takes care of that and I can always ask the staff for the address if the dispatcher wants it confirmed. 

2. 99.99% of the time, I can tell if I need to call for paramedics based on what I see at the doorway. If the patinet is breathing 40 times a minute and struggling with each breath, then I don't need to do an entire exam. As such, one provider can initiate assessment and treatment while the other goes tor request paramedics. 

3. Packaging and moving the patient can normally be done while paramedics are responding. As such, the patient can normally be in the ambulance by the time paramedics arrive without increasing the EMT's patient contact time->paramedic arrival time interval since initial assessment, treatment, packaging, and egress to the ambulance is done concurrent with the paramedic response and not prior to it.


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## medic417 (Mar 29, 2010)

bstone said:


> Here is a path of less resistance- move the PT into your ambulance, call for ALS. The NH will never know.



Actually if your service has the contract for transport and you call the 911 service to take the patient from your ambulance your service may have to pay.  If the patient still is in care of the nurses the nursing home foots the bill.


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## xsullyx (Mar 29, 2010)

wow dint know that was a possibility. 

my whole basis for refusing was not wanting to accept pt care then having the guy crap out on me.


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## CAOX3 (Mar 29, 2010)

Your allowed to refuse a call?


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## xsullyx (Mar 29, 2010)

well we're a transport company primarily, so whenn doing transports u can assess and then say " hey this is a bit outta my league". but since we are a bls squad with no als affiliation... its refusing to take the call and giving it to some als company. the only reason this can be done is because the pt is already under the care of a higher ranked care provider ( rn's ) and we hadnt yet assumed pt care. 

which is why it was particularyly messed up of them to "offer" to put the guy on our stretcher for us. because once hes on our stretcher we have pt care. all they cared about was gettin this dude out the door so they had one less round to do all night. no one in my family will ever go into a nursing home!


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## MrBrown (Mar 29, 2010)

OK this guy sounds a wee bit crook .... you know, just a bit.

If ALS can meet you on scene significantly faster than you can either deliver the patient to hospital or meet ALS enroute then stay on scene.

Significant is not defined and requires judgement.

Now because you canot do anything for this patient except what, bit of oxygen, I don't think there's much more you could have done!


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## DrParasite (Mar 29, 2010)

xsullyx said:


> well we're a transport company primarily, so whenn doing transports u can assess and then say " hey this is a bit outta my league". but since we are a bls squad with no als affiliation... its refusing to take the call and giving it to some als company. the only reason this can be done is because the pt is already under the care of a higher ranked care provider ( rn's ) and we hadnt yet assumed pt care.


you know, when you put it that way, it makes a lot of sense.  no sarcasm, that might be a legit response.


xsullyx said:


> which is why it was particularly messed up of them to "offer" to put the guy on our stretcher for us. because once hes on our stretcher we have pt care. all they cared about was gettin this dude out the door so they had one less round to do all night. no one in my family will ever go into a nursing home!


no, they didn't' want him to code on their bed, because if he does, then they need to work him.  or even worse, they knew he was beyond their capabilities, and called you to transport him to a more appropriate facility.

If I was in your position, I would have put the patient on the stretcher, and started wheeling him to the ambulance.  call for als on the scene, in the truck, enroute to the hospital, whatever.  I don't think refusing to do the job was the right thing to do, because it wasn't benefiting the patient (assuming they were doing nothing beneficial like most nursing homes I have dealt with).

the patient needed a hospital.  the patient was sick.  leaving the patient in the nursing home bed was the WRONG thing, because it wasn't helping the patient.  getting the patient to the hospital was the right thing to do.  getting the patient to the hospital with ALS treating was even better.  if the nearest ALS was on another assignment, or crashed while enroute to the nursing home, or was otherwise made unavailable, then what?  now you are waiting 10 minutes for the 3 min ALS unit.  then what?

load and go, call for ALS enroute.


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## xsullyx (Mar 29, 2010)

drparasite you may be right. leaving the pt with th rn's who dont care may have been the wrong choice because essentially he did need a hospital. however, one cant lose sight of the fact that rn's no matter how lazy are higher trained caregivers than my lowly bls self. ( im also kinda new so the protocols are my bible for now). 

but wouldnt have taking him, knowing his potential needs outweigh my training have been reckless. should i have gone all "wight knight" and taken him anyway? i tend to think not. admittedly my thought process was as much "cover my ***" as "what is best for this pt" but i guess when those two concepts came head to head i covered my ***. 

im kinda new at this and really respect/apreciate more experienced providers opinion of this scenario. thank u guys


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## triemal04 (Mar 29, 2010)

Don't actually "leave" the patient; whether or not you transport him, stay with him until the paramedics get there.  I'm sure you know that, so I'm just sayin'...B)

As for the rest of it...you did absolutely fine.  If ALS is closer than the nearest hospital (and be sure to take into account how long it will take them to get to the pt's side, not just on scene, as well as how long it will take you to load the pt and move to your ambulance, not just driving time to the hospital) then this would have been the appropriate time to call them.

The only thing you might do differently is to be completely up to date on how to get an ALS ambulance in that situation, confirm how long it will take them to arrive (to be sure it was the right call), and, once you've determined that you shouldn't be transporting him, don't argue with the staff; don't waste time but get him the help he needs.  Keep them in the loop about it, but, if it's your decision, then it's your decision.


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## CAOX3 (Mar 29, 2010)

Are nursing homes even able to treat medical emergencies?  Do they have standing orders in place, or do they have to await orders from an on call MD?

For the patients benefit next time I would prepare for transportation, as was stated if there was a delay on the ALS unit arriving, you can continue on to the hospital treating what you are able to.  

I am also not aware of any protocols that would require a BLS unit to wait until the arrival of an ALS unit.  Most state not to delay transportation.


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## medic417 (Mar 29, 2010)

CAOX3 said:


> Are nursing homes even able to treat medical emergencies?  Do they have standing orders in place, or do they have to await orders from an on call MD?
> 
> For the patients benefit next time I would prepare for transportation, as was stated if there was a delay on the ALS unit arriving, you can continue on to the hospital treating what you are able to.
> 
> I am also not aware of any protocols that would require a BLS unit to wait until the arrival of an ALS unit.  Most state not to delay transportation.



Most nursing homes have much higher standing orders than you basics have.  He did right saying lets stay here with you and the patient until the Paramedics arrive. 

 They did not delay care as it was shorter time to care getting started by waiting on the Paramedics.  

The do not delay transportation is for when no higher level is available not an excuse to risk patients lives because you still believe that basics save Paramedics.


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## CAOX3 (Mar 29, 2010)

Easy old timer, cluttering up this kids thread with your opinions of me isnt getting them anywhere closer to the answer they are looking for.

If you want to discuss what I believe in feel free to PM me.  K, thanks.

Sully you would need to consult your medical control or protocols to determine what is appropriate action in this situation.


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## JPINFV (Mar 30, 2010)

Something else to consider with SNFs in terms of the "who higher" debate. On one hand, the nursing staff can do a lot more interventions both on standing orders (written orders and protocol orders) as well as physician phone orders. The one thing they absolutely can not do, though, is transport to the ER. Sometimes it's better to decrease the amount of care immediately available to achieve a higher level of care down the road.


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## xsullyx (Mar 30, 2010)

oh believe me prtocols and medical command were followed and in that order. i might be newly cert'd but im not playin games out here

i think the central issues here are, follow protocol closely, follow gut and pt needs perhaps more than your own, and finally, my bosses want to make all the money they can... protocols or not.


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## MusicMedic (Mar 30, 2010)

I think you did the right thing, If ALS is closer, wait for them.. because if the Patient crashes En Route, theres not many interventions BLS can do.. and honestly he really did not sound stable at all.. 

I had a similar Call the other day, (i work for a transport company too) 

Nursing Home calls Dispatch, Dispatch Calls us for CVA... we show up, patients Chief Complaint of Crushing Chest pain radiating down her left arm 6 Hours ago, Paitent is currently not having any pain at all, My partner does a quick Medical Eval, Vital Signs are stable, patient is very stable... we decide not to call ALS because, the patient is stable and the Fire Medics would most likely send it BLS anyways (in Orange County they BLS everything unless its Life-threating), We call our supervisor, she okays it.. We Load her up and take her to an ER, find out she has a Minor Left Branch Infarct.. Now one of the Paragods/Ricky Rescue at our station overheard the call, and started to give us :censored::censored::censored::censored: because we didnt call ALS or go Code on the call, but we both knew he was a jackass and the patent was stable

but you have to love IFT Company Drama!!


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## Akulahawk (Mar 30, 2010)

JPINFV said:


> Nope... never had a problem at my old place with requesting paramedics. Of course requesting paramedics was easy. Pick up the phone, call 911, advise 911 dispatcher that this was a BLS crew. I never advised the nursing staff that I was requesting paramedics until I was on the phone with the 911 operator.
> 
> Something to remember, though. *If transport time to the closest hospital is less than the paramedic response time, then just transport* unless you don't have enough providers on scene to provide care (i.e. cardiac arrest).


I've seen some SNF's do some whacked things over the years...
Where I used to work about 10 years ago, local protocol authorized exactly this. At the time, the "clock" started when the EMT made patient contact. The SNF folks KNEW this as well, so they'd call BLS for (quite literally) everything short of a full arrest, with a full code patient. Since many of the SNF's were close to a hospital, they knew that a BLS crew could get the patient to the ED faster than 911 could. They also knew that the bill would be much lower... 

A few years later, the county changed to requiring an interval of 10 minutes from arrival on scene to arrival at the ED, if the patient was unstable. The crew was to call 911/county comm and determine if the ETA for ALS was quicker than their own transport ETA. Since the arrival time to ED ETA time would almost ALWAYS be more than 10 minutes... The SNF's "learned" and stopped calling BLS for all the stuff they used to and started calling 911. Surprises happened from time to time, but those were usually en-route. 

Eventually, ALS-IFT became authorized and the SNF's started calling for that instead for those patients that were unstable and didn't want to have to have another 911 call on their books...


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## Shishkabob (Mar 30, 2010)

Keep in mind, just because they are "nurses" doesn't mean they can do better for your patient than you can.



CPR on the xiphoid process anyone? :glare:




You'll gain experience, and with that you'll know what will be better for your patient then you think now.  And if something totally throws you through a loop, grab your phone and call dispatch.


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## 8jimi8 (Mar 30, 2010)

BTW,

most RNs at a SNF are usually in supervisory positions i.e. they have 60 patient's they are responsible for.

let's be careful about bashing other medical professionals.

Even still... an LVN has more education than a basic or an intermediate.  

So let's play nice, eh?  I can give you just as many examples of sub-par EMTs.


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## firecoins (Mar 30, 2010)

I don't know how your system works.

BLS IFT don't refuse calls per se.  They call ALS and load the patient in their rig.  We go on board their rig and transport the patient in the BLS rig.  The ALS rig is driven by the other medic.


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## Shishkabob (Mar 30, 2010)

I stand by what I said:

Just because they have the word "nurse" in their title does not instantly make them better for your patient than you are.

From the moment you get dispatched, that patient is yours.  If you deem something is or is not needed (preferably IS at a basic level) then it is your responsibility to handle the need.  If a nurse disagrees, she can go through the proper channels.


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## xsullyx (Mar 30, 2010)

have two issues with that linus.

first being that, as a higher level of care provider, a nurse is better than a basic. regardless of dedication to the job or attitudes or egos their education makes them better... or should but most importabtly does in the eyes of the state. 

consider this: if you have come upon a cardiac arrest while at the store or sumthing and there is a first responder and a bystandetlr doing cpr. you can come in and take the scene as a higher care provider. i think the same applies to this situation just in a less emergent fashion.

second, this is not 911 this transport. emergent transport but transport nonethe less. he is already in the care of a higher level provider so the patient is most certainly not mine upon dispatch.

if i had taken the patient and not called als just to get him to the hospital, and the guy crapped out enroute, i really believe id be standing in front of the regional ems council explaining why i didnt call 911 for als or even have any business taking care from the nurse in the first place as a basic


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## 8jimi8 (Mar 30, 2010)

The point i was making was not about being a "better" provider.  The point i was making was that we shouldn't make sweeping generalizations about such things as, "Nurses don 't know how to do CPR."  I understand that Linuss had a run-in with some "nurses" doing cpr in the incorrect position.  Again, that is the provider that you encountered, not all of us.

Especially when you run into a situation where the provider is an LVN.  That is one year of school... Degreed paramedics definitely have more education than an LVN.  Especially when you start looking at emergency situations.  I can see a Basic having more experience than an LVN when it comes to emergencies.  These nurses may not have had the experience to deal with the situation and that may be why they were freaking out when the op wanted to call 911.

I think the OP made the correct decision.  

I still denounce any and all sweeping, blanket generalizations where one provider says i'm better than so and so, or all so and so's don't know anything.

Sorry Linuss, you are wrong on this one.

We are all on the same team.  Sometimes basics save paramedics, sometimes nurses save doctors and sometimes not even God will save you.  

So let's look at the facts and avoid denigrating our teammates, eh?


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## Shishkabob (Mar 30, 2010)

*Sigh*

More education does not always equate better.  Anyone who's been in the field a while has seen their share of stupid nurses, AND stupid EMTs and medics.  It's on both sides of the fence, and has little correlation to education. 

Just because they are a nurse does NOT make them your superior or have control over the scene (dependent upon your local laws and your own protocols).




> if i had taken the patient and not called als just to get him to the hospital, and the guy crapped out enroute, i really believe id be standing in front of the regional ems council explaining why i didnt call 911


  And where has ANYONE disputed that?  But, as has been stated multiple times in this thread, you have to weigh waiting on scene for ALS and initiating rapid transport... DO NOT delay getting your patient to definitive care, and NO, the nurses at the nursing home are not definitive care.  They called you because they are no longer able to cope with the patients condition.

Again, you need to do what's in the best interest of your patient, and the best way to do that is follow your protocols and contact med control if you have to.


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## Shishkabob (Mar 30, 2010)

8jimi8 said:


> I still denounce any and all sweeping, blanket generalizations where one provider says i'm better than so and so, or all so and so's don't know anything.
> 
> Sorry Linuss, you are wrong on this one.



I said, and I quote:

"just because they are "nurses" doesn't mean they can do better for your patient than you can."


Where's the sweeping generalization?  I never said all nurses sucked, or most nurses suck, or all EMTs are better then all LVNs.  I said don't make assumptions that just because they have nurse in their title does not make them better than you, or that they can only do good and not bad... how is that a wrong rationalization?




You're preaching to the choir of not making generalizations based on certification!  I've always called people out on this forum who do something of that nature, so why would I turn around and be a hypocrite?


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## JPINFV (Mar 30, 2010)

xsullyx said:


> have two issues with that linus.
> 
> first being that, as a higher level of care provider, a nurse is better than a basic. regardless of dedication to the job or attitudes or egos their education makes them better... or should but most importabtly does in the eyes of the state.


Education isn't nearly as important as the ability to intervene. Now let me clarify that the ability to intervene *must* be backed up by a proper education, but if I had a choice between a cardiologist fresh out of a fellowship or a PhD who has devoted his life to studying MIs taking me to the cath lab, I'll take the cardiologist even though the PhD is more educated about MIs than the physician. Similarly, an ambulance crew, regardless of basic, paramedic, or anywhere in-between, has one major intervention that is not available to the nursing home staff. The ability to transfer. I would argue that any critical care transport results in a transient decrease in the level and ability to care for the patient (i.e. accepting care from the transfering facility and during the transport), but results in the end in achieving the goal of giving the patient a higher level of care (delivery to a specialty center). As such, outside of only a handful of situations (i.e. cardiac arrest), I can't see any reason why a basic level crew should refuse a patient. Call paramedics? Sure. Transport emergently to the nearest emergency department, rerouting if need be? Sure. Just saying, "Sorry, this patient is too sick to take to the emergency department by us, call someone else"? Never. 

Now this is not to say that you shouldn't:
1. Request paramedics.
2. Initiate treatment. 
3. Package and engress to the ambulance in preparation of paramedic arrival.
4. Assist paramedics when they arrive, up to and including, transporting with paramedics on board your ambulance.  



> second, this is not 911 this transport. emergent transport but transport nonethe less. he is already in the care of a higher level provider so the patient is most certainly not mine upon dispatch.


You are on a call originating someplace out in the community (a nursing facility) where the requested termination point of the transport is an emergency department. You *are* an *emergency ambulance* in this situation. Saying, "... but... but...but we're not a 911 ambulance" is, in all honestly, a cop out. Do you really think you are that much different than an EMT-B working for a 911 company? 




> if i had taken the patient and not called als just to get him to the hospital, and the guy crapped out enroute, i really believe id be standing in front of the regional ems council explaining why i didnt call 911 for als or even have any business taking care from the nurse in the first place as a basic



Personally, I'd rather describe how a patient crashed during a short transport to the closest emergency room (which, according to you, was not the case with *this* patient), than crashed in the back of my ambulance as I sat on scene waiting for the paramedics longer than it would have taken me to get to the emergency room.


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## Veneficus (Mar 30, 2010)

JPINFV said:


> I would argue that any critical care transport results in a transient decrease in the level and ability to care for the patient (i.e. accepting care from the transfering facility and during the transport), but results in the end in achieving the goal of giving the patient a higher level of care (delivery to a specialty center)..



You mean an ancillary provider of some type and a nurse isn't the same level of care as a hospital unit full of specialists? 

I'm devastated.


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## JPINFV (Mar 30, 2010)

Veneficus said:


> You mean an ancillary provider of some type and a nurse isn't the same level of care as a hospital unit full of specialists?
> 
> I'm devastated.





Only if one of Mary Mundinger's DNPs is the nurse on board the ambulance.


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## 8jimi8 (Mar 30, 2010)

Linuss said:


> I said, and I quote:
> 
> "just because they are "nurses" doesn't mean they can do better for your patient than you can."
> 
> ...



sorry dude sometimes i'm retarded


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## jgmedic (Mar 30, 2010)

JPINFV said:


> Education isn't nearly as important as the ability to intervene. Now let me clarify that the ability to intervene *must* be backed up by a proper education, but if I had a choice between a cardiologist fresh out of a fellowship or a PhD who has devoted his life to studying MIs taking me to the cath lab, I'll take the cardiologist even though the PhD is more educated about MIs than the physician. Similarly, an ambulance crew, regardless of basic, paramedic, or anywhere in-between, has one major intervention that is not available to the nursing home staff. The ability to transfer. I would argue that any critical care transport results in a transient decrease in the level and ability to care for the patient (i.e. accepting care from the transfering facility and during the transport), but results in the end in achieving the goal of giving the patient a higher level of care (delivery to a specialty center). As such, outside of only a handful of situations (i.e. cardiac arrest), I can't see any reason why a basic level crew should refuse a patient. Call paramedics? Sure. Transport emergently to the nearest emergency department, rerouting if need be? Sure. Just saying, "Sorry, this patient is too sick to take to the emergency department by us, call someone else"? Never.
> 
> Now this is not to say that you shouldn't:
> 1. Request paramedics.
> ...



While in principle I agree JP, having worked behind the Orange Curtain, how many times have RN's and MD's gone about 3 feet up your *** about bringing in an "ALS" patient BLS. Having worked for Care and CRA, I've seen it both ways, I have gotten my *** chewed for bringing in patients and not waiting for medics, and I know tons of other EMT's in the same predicament, that have been told to always wait for medics, and then received another reprimand from supervisors for the same thing. Not saying it's right, but unfortunately, in the back-asswards universe of OCEMS it's what they wanted.


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## Veneficus (Mar 30, 2010)

JPINFV said:


> Only if one of Mary Mundinger's DNPs is the nurse on board the ambulance.



While I have seen many capable NPs (and a few who probably shouldn't be allowed to continue practicing) The DNP program curriculums I have seen are woefully inadequate to equal or replace a physician. It is a low cost alternative for those who cannot afford a doctor.

The idea of “doctor nurse” is faulty. An 8 year nursing degree doesn’t equal the minimum of 11 years of a medical degree with a bunch of “nursing practice” clinicals.

The only advanced nursing curriculum I have seen that I can respect is the CRNA. In the comparisons I have seen, they come the closest in terms of scientific work. 

If calling themselves “doctors” stokes their ego, so be it I guess, but to call it equal is just ignorance or hubris. 


It must be nice to get recognition for a basic dx.
http://online.wsj.com/public/article_print/SB120710036831882059.html

How astute, she figured out the complication of one of the most common diseases in medicine. Wonder if I could have passed my rheumatology clinical much less garner some praise without such profound knowledge?

*"Edwidge Thomas, a doctor of nursing practice, noticed something in her blood test that indicated a form of rheumatic infection linked to her arthritis."*

Then she sent the patient to a real doctor. A proud day in nursing history I guess.

*"The diagnosis was confirmed when Ms. Gleason was referred to a neurologist, who prescribed medication."*


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## JPINFV (Mar 30, 2010)

jgmedic said:


> While in principle I agree JP, having worked behind the Orange Curtain, how many times have RN's and MD's gone about 3 feet up your *** about bringing in an "ALS" patient BLS. Having worked for Care and CRA, I've seen it both ways, I have gotten my *** chewed for bringing in patients and not waiting for medics, and I know tons of other EMT's in the same predicament, that have been told to always wait for medics, and then received another reprimand from supervisors for the same thing. Not saying it's right, but unfortunately, in the back-asswards universe of OCEMS it's what they wanted.




Did it happen to me when I worked for Lynch (on a side note, I worked for Lynch from 2005-2007, which was before Dr. Stratton took over OCEMS and the system actually began writing BLS protocols besides the ETA transport clause)? Sure. At the same time I've had hospital staff completely understand where I'm coming from and why I've done what I've done. Other times I've been yelled at for not calling 911 despite being 1 minute away and only passing a stop sign (I love you too HBMC). Now I've done a few things also. In the end, I have to be able to go home at the end of the shift knowing I provided the best possible care I can. That includes not calling paramedics when my transporting 0.5 miles that consists of a right turn and 2 lefts. I'd rather explain why I transported a patient (who in this case was in a 3rd degree heart block) 2-3 minutes than wait for paramedics on scene. I'd rather explain not calling paramedics for the non-verbal patient that the SNF staff said is "complaining of chest pain" when the nearest hospital is 0.2 miles away on the same side street (The HBMC incident) and any responding FD units would have to pass the hospital on their way to the facility. I am definitely not above having a copy of the transport protocol [PDF. Top of page two. The V/S and reporting requirement were added after I left] with me and providing it to the staff with my PCR and the rest of the patient's package. If bad things happen, I'd much rather stand before my company or county EMS and explain why I transported emergently to the closest ED than sat on my hands waiting for paramedics longer than it would have taken to transport.

If an RN gets mad at me, I don't take it personally. Yes, I know my interventions are very limited and, in many cases, useless for the patient as presented. However it still comes down to the fact that I ultimately can transport and reroute to the nearest hospital. The only times I can think of right now where I can justify requesting paramedics regardless of ETA vs transport time is when I have an extended egress ETA (call early is my motto for requesting paramedics. They can respond while the patient is making his/her way to the ambulance), cardiac arrests, when I need assistance moving the patient, or in a "X hospital or I sign AMA" (assuming unstable patient) case. The hospital staff can whine as much as they want, but I ultimately report to county EMS and my company for the appropriateness of my care and the decisions I make and not to them. 


On a side note, I highly advise any EMT-B to keep a copy of uncommonly used, controversial, or generally not well understood protocols in their personal clipboard. I kept a copy of the transport protocol and the DNR protocol (the DNR protocol is very liberal in OC and different than most 'standard' protocols as taught in school). Additionally, I had a printout of the elder abuse procedure, elder abuse reporting form, company incident report form, and a preaddressed, stamped envelope in my backpack. The last thing I want to do is get into an argument with a partner on scene that doesn't know the protocols (yes, in OC we can take a verbal request to "withdraw or withhold resuscitation" from a family member) or trying to figure out how to report abuse on the fly.


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## ochacon80 (Mar 30, 2010)

Our owner advised us that there should never be any reason for us to call ALS. He always jaws about how our protocol states that if we are within 5 minutes of any ER its an automatic transport. He doesnt take into consideration what type of condition the Pt is in, or if they need any interventions prior to transport. Truth be told, for most of these owners its all abot the money. Every call that we dont take is money lost in their pockets. Marketers for some private companies are the worst. I know of plenty of BLS companies that make promises to Con Homes that 911/ALS will never be called, if they give said company more calls. It really makes me sick the way a lot of companies here in LA operate.


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## JPINFV (Mar 30, 2010)

ochacon80 said:


> Our owner advised us that there should never be any reason for us to call ALS. He always jaws about how our protocol states that if we are within 5 minutes of any ER its an automatic transport. He doesnt take into consideration what type of condition the Pt is in, or if they need any interventions prior to transport.



If the hospital is 5 minutes or less away (which, to be fair, the actual protocol for LACo is time based as well*), what intervention is worth delaying transport for more than 5 to wait on scene for paramedics for outside of a cardiac arrest? Let's say the paramedics respond. 4-6 minute response time is reasonable. The problem is that it's not like they arrive and then just magically whip out the intervention. They're going to take report from you, from the staff, and conduct their own assessment. If, say, the patient needs some sort of IV medication (let's say D50 for hypoglycemia), then they're going to have to start an IV. The patient is still going to have to be packaged and still going to be transported. Alternatively, in that 4-6 minute range, you transport yourself. The patient still receives the care that the paramedics could provide plus additional emergency care from the emergency department staff. The only difference is that you've cut out that 10 minutes that the paramedics are going to spend on scene assessing and treating prior to transport. 


*Principal number 7, "In life threatening situations, consider BLS transport if ALS arrival is longer than transport time." Protocol attached below since LACo's website sucks.


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## ochacon80 (Mar 30, 2010)

So as BLS providers are we basically damned if we do damned if we dont? I have been verbally raped by nurses on more than a few occasions for transporting what they consider ALS patients. I have also been yelled at by my marketing staff and owner for as they put it "takking money from the company"

Now heres another question I need clarification with. Our protocol states if transport to a hospital is less time that ALS response then we transport. But protocol also states that ALOC, SOB, and Chest pain are base contact ALS. What do we do in this situation? I have had SOB pts and I chose to transport, but again, I got reamed.


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## JPINFV (Mar 30, 2010)

In that sense, yes. Excrement rolls downhill. Always. However, consider the fact that the best that nurses can do is yell. The boss and the marketing staff is a bit harder to deal with and brush off. However if I've got a paramedic unit across the street from my location, then there's no way I can justify not calling.  

First off, can EMT-Bs in LACo make base hospital contact? 

Second off, you transport even if you can't make contact. Ideally, you should have some method of alerting the hospital that you're coming in even without base hospital contact. For example, the company I worked for in OC had us give a 5 second report (age/sex/PMD/CC/ETA/anything extremely pertinent like BP for a hypotensive patient), and the dispatchers called the hospital. So the hospital shouldn't be completely unaware that you're coming in. The only possible exception (which, again, needs to be handled by a protocol adjustment to cover you) are things like MIs that may be retraiged to a cath lab even if it isn't the closest hospital. However until that exception is put in place, it's safer to transport to the closest hospital. If worse comes to worse, provide the hospital staff with a copy of your protocol and tell them to go complain to LA County Local EMS Authority (LEMSA) about that policy. 

I also question about how calling for paramedics is 'taking money from the company.' The paramedics (especially if it's a non-transporting fire department) shouldn't be having you hand over care to other ambulance companies for transport. They should be transporting the patient on your ambulance. This issue got so bad for Lynch when I was there that then medical director Dr. Haynes (now medical director for San Diego County LEMSA) had to send out a letter condemning the actions of the fire department for having us transferring care to Care when paramedics were requested. In the same letter, he condemned the crew for calling paramedics because they should have been able to transport to the nearest hospital in about as much time as it took the paramedics to respond. However, fighting the fire department about issues like that on scene are counterproductive and, in my opinion, above my pay grade as an EMT-B.


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## CAOX3 (Mar 30, 2010)

Our protocols simply state do not delay transport, activate ALS if determined to be neccesary.  Simple.

Do whats in the best interest of the patient.


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## eveningsky339 (Mar 31, 2010)

Now let's just hang on here...  I have a few words...

Even though a nursing home RN is technically a "higher" level of care, I would never under any circumstances leave a patient with them before ALS arrived.  

I worked as a CNA for a few months in a nursing home, and I encountered quite a few horror stories (and real situations) about RN/LPN responses to emergency situations.

For example, one night there was a resident who, at the start of the night shift, complained of chest pain and difficulty breathing.  He was full code status.  The charge nurse, however, did not know what to do.  So, she waited for *eight hours* until the day shift nurse came in, who also did not know what to do.  So, they called 911.  The patient had been dead for a fairly long time when the ambulance showed up.

To be fair, there are some awesome nurses that work in nursing homes, who genuinely enjoy geriatrics.  But eighty percent of the nurses I encountered as a CNA were per diem, can't-get-a-hospital-job nurses.  It was awful.

I've never been on a "pure BLS" truck, but if I ever was, I would never leave a patient with a nursing home RN.  h34r:


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## jgmedic (Mar 31, 2010)

JPINFV said:


> In that sense, yes. Excrement rolls downhill. Always. However, consider the fact that the best that nurses can do is yell. The boss and the marketing staff is a bit harder to deal with and brush off. However if I've got a paramedic unit across the street from my location, then there's no way I can justify not calling.
> 
> First off, can EMT-Bs in LACo make base hospital contact?
> 
> ...



LOL. was that your pt I took out of a Lynch rig? Lemme guess, Fullerton or Anaheim FD? I've run into nurse issues at a lot of OC hospitals, but especially the beach areas(I'm looking at you Hoag). I hate the fact that dispatchers call in report. At Care. we called in our own reports, but at CRA, they hated that I did that so much, they took all the hospital phone numbers out of the unit phones. Now, as a medic the con homes will call for a non-911 ALS call. But sometimes, we will get a call to the con home in the parking lot of our local receiving ED for a BLS unit on scene of an ALS call, the crew could literally walk the pt across the lot to the bay doors faster than I could go from my unit to the pt's room.


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## JPINFV (Mar 31, 2010)

jgmedic said:


> LOL. was that your pt I took out of a Lynch rig? Lemme guess, Fullerton or Anaheim FD?


2006 time frame, Anaheim Fire at the off site nursing facility on Beach for the Anaheim hospital that recently lost JACHO accreditation? 



> I've run into nurse issues at a lot of OC hospitals, but especially the beach areas(I'm looking at you Hoag).



You know, it's funny because Hoag was the one hospital that I've never had a problem with. It might have been because I went through the college volunteer program (CCE program) there during my undergrad so I knew a bunch of the nurses. St. Joseph's on the other hand...


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## jgmedic (Apr 1, 2010)

JPINFV said:


> 2006 time frame, Anaheim Fire at the off site nursing facility on Beach for the Anaheim hospital that recently lost JACHO accreditation?
> 
> 
> 
> You know, it's funny because Hoag was the one hospital that I've never had a problem with. It might have been because I went through the college volunteer program (CCE program) there during my undergrad so I knew a bunch of the nurses. St. Joseph's on the other hand...



West Anaheim MC. Haha, I was on the Stanton unit for years and that was our primary receiving. I cannot stand AFD, except for E-4, I have gotten nothing but shabby treatment from them, if you weren't on an in-house AFD ambo, they could care less about respect and courtesy.


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## John E (Apr 5, 2010)

*Wow...*

it's hard to believe that so many of you missed what was really happening in the OP's scenario.

Some random points.

It's a virtual guarantee that the owner of the transport company and the owner/operator of the con home have some sort of financial agreement whereby the ambu. company gets called for their transports in exchange for a kickback from the ambu. company.

The con home gets investigated when they call for ALS transport too many times, that leads to the owners/operators getting fined or losing patients, ie, money.

The ambu company thinks that the OP was costing the company money because they can't defraud Medicare or bill the patient's insurance company if the patient ends up being transported by either the ALS company or by public/FD ambulance.

The "nurses" at the Con home are either aware of the financial arrangements that have been made between the owners and the ambu company or they themselves have also been convinced financially thru bribery to call that particular company for transporting patients. 

None of what transpired has anything to do with the educational standards of EMS or the legal standing of an RN vs an EMT in regards to authority over patient care. It has to do with money. 

John E

P.S. to the original poster, you did exactly what you should have done from a patient care POV, unfortunately the patient care POV is ALWAYS secondary to the financial interests at play in the private/transport ambulance company world.


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## JPINFV (Apr 5, 2010)

Oh, I don't think anyone ever missed that point. However, points such as, 


xsullyx said:


> well we're a transport company primarily, so whenn doing transports u can assess and then say " hey this is a bit outta my league". but since we are a bls squad with no als affiliation... its refusing to take the call and giving it to some als company. *the only reason this can be done is because the pt is already under the care of a higher ranked care provider ( rn's ) *and we hadnt yet assumed pt care.


 (emphasis added)

deserves discussion.


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## jeeprnovru (Apr 9, 2010)

i would have just wanted to transport with possible als intercept in route....you guys can do that over there i hope....h34r:


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## spike91 (Apr 26, 2010)

I volunteer in New York, and when we get a patient that we feel is in need of ALS, we request the ALS and continue with transport unless an ALS provider is in the immediate vicinity. Otherwise we'll do an intercept with the provider, he'll jump on our rig and get to work en route. 

Keep in mind, however, all of our rigs are ALS equipped, so I can imagine many wouldn't be capable of this kind of set up.


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## firecoins (Apr 26, 2010)

A nursing home is not really a higher level of care.  It might be technically but the RNs in a nursing home can not do anything w/o MD approval.  When we accept care, the RNs are not a qualified 911 receving facility. BLS units are free to all for medics reguadless of the desires of the SNF.


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## JPINFV (Apr 26, 2010)

firecoins said:


> A nursing home is not really a higher level of care.  It might be technically but the RNs in a nursing home can not do anything w/o MD approval.  When we accept care, the RNs are not a qualified 911 receving facility. BLS units are free to all for medics reguadless of the desires of the SNF.



Technicalities have a tendency to hang people.

EMS providers can't do anything either without physician approvial (who do you think signs your protocols/standing orders? Do you think EMS is the only place with standing orders?)? Additionally, what PRN orders are currently written for that patient? 

I'm not, and will almost never say, not transport or accept a patient with an emergency from someplace in the community for transport to an emergency department. However there's better arguments than the "EMS has psuedo-independent practice rights" argument that gets thrown around every time someone feels the need to compare EMS providers to nurses. How about this argument? The ends (emergency department) justify the means (EMS transport, even if by EMTs).


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## firecoins (Apr 26, 2010)

JPINFV said:


> Technicalities have a tendency to hang people.
> 
> 
> 
> ...


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## Akulahawk (Apr 26, 2010)

firecoins said:


> JPINFV said:
> 
> 
> > Technicalities have a tendency to hang people.
> ...


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## JPINFV (Apr 26, 2010)

Akulahawk said:


> I'd transport if the ED was closer time-wise than the nearest ALS ambulance or engine (I worked BLS at the time) and turn over to ALS if the reverse was true.





JPINFV said:


> I'm not [saying], and will almost never say, not transport or accept a patient with an emergency from someplace in the community for transport to an emergency department.





/shrugs...
//forgot a word, but is implied by what was placed in the comma section...
//Wonders if people read entire posts anymore...


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## Akulahawk (Apr 26, 2010)

JPINFV said:


> /shrugs...
> //forgot a word, but is implied by what was placed in the comma section...
> //Wonders if people read entire posts anymore...


JP: I understood what you meant.


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## MonkeySquasher (Apr 30, 2010)

Sully -

DrParasite hit the nail on the head.  You are, at all times, a patient advocate.  Always do the right thing for your patient, and what your patient needs.

You aren't so "lowly" of an EMT at the Basic level...  His BP was in the tank, yes.  I'm assuming the NH can't do IVs, so you're on your own.  Oxygen, Trendelenburg position, cover with a blanket, package into your ambulance for transport...  All things you can do to benefit your patient, and not feel helpless.  Sure, they aren't the "silver bullet" for his condition, but it's better than a phone call and waiting period.  Then ALS gets there, he's already in the ambulance.  They do an IV, and do the monitor and any further treatment during transport.

Now I know saying this may anger some who read this, but...  You, as a Basic EMT, are a BETTER level of care when you show up.  Many NH/SNF can do more than you can, but as stated, they can't transport.  And to do interventions, they have to call an MD for Orders to do pretty much anything not already in writing, as PRN meds are rarely emergency-oriented.  You, meanwhile, operate under standing orders for treatments based on patient presentation, and can then just package up and rush to a hospital if things go south.

Sully, I don't know about PA, but in my state, on an ambulance, a typical RN is the same level of care as a Boy Scout, unless doing an IFT under orders of an MD, or a CCN, or something.  As Linuss stated, "They called you because they are no longer able to cope with the patients condition."   When you get there, you make patient contact, you are now incharge.  And since that patient is unstable, your clock is ticking.  Waiting 5 minutes for ALS won't burn you, no.  But that doesn't mean you don't initiate treatments and begin packaging, you know?

However, watch closely EVER refusing to take someone while at work.  Saying "I won't take this person for X Y Z reasons" is a good way to get fried some day, unless (like you said) you somehow have a doctor backing you up.  And document the hell out of it, with names and time and signatures, if possible.

If you had started transport and the guy's condition worsened, it's the same as any other patient.  Follow your proper protocols and work it into the hospital.  Being BLS, there's only a handful of things you can do, so you should have no excuse not doing all of them.

There's a quote from the movie SWAT which I stand by...  "Sometimes 'doing the right thing' isn't doing the right thing."  Remember - You can never be faulted for doing what you truly believe to be in your patient's best interests.


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## Rsion4191 (May 5, 2010)

At most NHs , nurses need an MDs approval (as previously stated) . But even here in SoCal , MDs AREN'T EVEN AT THE NHs . They've gotta wait for phone orders or wait for written orders to be brought in . I understand how you feel about being new . I've only been in the field for six months as well .


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