# LA County Fire.....



## Chris31 (Nov 29, 2014)

So here's my dilemma. I've been a 911 responder with a private ambulance company contracted with LA County Fire for over a year now.  I've noticed a pervasive practice by Fire EMT's and Medics alike, which has become more common as call volumes increase.  Almost every shift now, I catch a firefighter or paramedic "faking vitals" in order to circumvent LA County ALS criteria and ship a patient BLS.  Granted these are usually ETOH or Behavioral patients, In a few incidents, its turned out to be a stroke patient or a STEMI.  I'm talking about lying about 12-lead results to base when one wasn't even preformed, or glucose readings which are completely false (101 when it was actually 425).  I voiced these concerns first to a paramedic on scene when we were asked to ship a stroke patient bls, and was met with instant retaliation by the entire battalion on scene for questioning a paramedic's assessment skills.
Now, I understand the caliber of Southern California private ambulance EMTs can sometimes be lacking, and this can leave fire with a "bad taste in their mouth", but a good assessment is a BLS skill and when it comes to patient care on scene, its a group effort to provide the best care possible for a patient.  
I was informed by a fire captain after the fact, that I was out of line for questioning his medic, and that EMT's are NOT to preform assessments because ALS Paramedic assessments are superior, and render EMT assessments obsolete.  

Now obviously, I know this to be completely false, but it shows that as far as the internal workings of LA County Fire are concerned, medics can do no wrong.  My question to all of you is; how would you address this breakdown of patient care, and most importantly, address Fire faking vitals in the interest of shipping a patient BLS?


----------



## chaz90 (Nov 29, 2014)

If you've already mentioned it to the fire medics themselves and their direct supervisors, go higher. Make a paper trail, get names of who you have spoken to, and go up their chain of command. Lying about vitals or procedures that weren't performed is a serious dereliction of duty and deserves to be dealt with severely. Honestly, I'd push up the chain until I got results from someone. You may not be the most popular guy around in the fire service's eyes, but someone has to effect change at some point.


----------



## gonefishing (Nov 29, 2014)

Chris31 said:


> So here's my dilemma. I've been a 911 responder with a private ambulance company contracted with LA County Fire for over a year now.  I've noticed a pervasive practice by Fire EMT's and Medics alike, which has become more common as call volumes increase.  Almost every shift now, I catch a firefighter or paramedic "faking vitals" in order to circumvent LA County ALS criteria and ship a patient BLS.  Granted these are usually ETOH or Behavioral patients, In a few incidents, its turned out to be a stroke patient or a STEMI.  I'm talking about lying about 12-lead results to base when one wasn't even preformed, or glucose readings which are completely false (101 when it was actually 425).  I voiced these concerns first to a paramedic on scene when we were asked to ship a stroke patient bls, and was met with instant retaliation by the entire battalion on scene for questioning a paramedic's assessment skills.
> Now, I understand the caliber of Southern California private ambulance EMTs can sometimes be lacking, and this can leave fire with a "bad taste in their mouth", but a good assessment is a BLS skill and when it comes to patient care on scene, its a group effort to provide the best care possible for a patient.
> I was informed by a fire captain after the fact, that I was out of line for questioning his medic, and that EMT's are NOT to preform assessments because ALS Paramedic assessments are superior, and render EMT assessments obsolete.
> 
> Now obviously, I know this to be completely false, but it shows that as far as the internal workings of LA County Fire are concerned, medics can do no wrong.  My question to all of you is; how would you address this breakdown of patient care, and most importantly, address Fire faking vitals in the interest of shipping a patient BLS?


I've witnessed this several times in the ED.  Contact LACDHS or the ems office.  Like the previous comment before make a paper trail that way no funny business happens.  Always remember that could be your loved one or friend on that cot.  Most of these guys do it for the bump in pay and could give 2 damns about the patient.


----------



## titmouse (Nov 29, 2014)

Well thats what happens when you have fire medics,  most of them hate the ems side of the job but they have to do it because theyre required. The sad part is that in the end the ones that suffer are the patients.


----------



## gotbeerz001 (Nov 29, 2014)

While you're at it, write up the crusty burnt-out single role medics which are (at least) a 1:1 trade for a lazy fire medic. 

I do not condone short-cutting assessments, but the problem is not limited to FDs. Let's stay on point and agree that poor patient care is the problem regardless of the patch.


----------



## gotbeerz001 (Nov 29, 2014)

So let me try to understand the situation:
In LA County, you have both BLS and ALS 911 transport rigs; you are on one of these BLS rigs. First Responders will arrive and do an assessment to determine which level of transport is required. Your claim is that vital signs have been falsified to justify a lower-level transport. 

My questions:
Do ALS units take longer to respond than BLS units?

If not shorter scene times, is there some advantage for LACoFD to send the pt with you as opposed to an ALS unit?

Does FD provide you with Field Notes or a "fire sheet" during hand-over?


----------



## Jim37F (Nov 29, 2014)

In addition to the above, use your PCR's to document EVERYTHING. If you have to write in your narrative that you felt the patient should have gone ALS but was only sent BLS, write it. If no 12 lead was done, and you believe it was indicated, Write no 12 lead performed on scene, etc etc etc. Don't just write LACoFD, be specific which squad and engine were on scene with you. Do the same when giving your handover report to the hospital. Tell the nurses exactly why you think the patient should be ALS, what the medics on scene did and did NOT do. Make your official reports to the County FD HQ, your company, and the County EMSA. But in the immediate meantime, care as best you can for the patient you have, don't be afraid to say you need to divert to the SRC/ASC....if you can, learn the phone numbers to the local hospital EDs or even the base station if need be.


----------



## Jim37F (Nov 29, 2014)

gotshirtz001 said:


> So let me try to understand the situation:
> In LA County, you have both BLS and ALS 911 transport rigs; you are on one of these BLS rigs. First Responders will arrive and do an assessment to determine which level of transport is required. Your claim is that vital signs have been falsified to justify a lower-level transport.
> 
> My questions:
> ...


LA County Fire does not have any transport capabilities, ALS or BLS. Instead, they respond to medical calls with a fire engine and a squad, with a private company BLS ambulance. The squad is a dual medic ALS unit that has no transport capability. For ALS level calls, a medic off the squad will hop in the back of the ambulance with the EMT and the squad and ambulance will transport to the hospital while the engine goes back into service. For BLS level calls, both engine and squad will go back into service while the BLS ambulance transports.


----------



## gotbeerz001 (Nov 29, 2014)

Jim37F said:


> LA County Fire does not have any transport capabilities, ALS or BLS. Instead, they respond to medical calls with a fire engine and a squad, with a private company BLS ambulance. The squad is a dual medic ALS unit that has no transport capability. For ALS level calls, a medic off the squad will hop in the back of the ambulance with the EMT and the squad and ambulance will transport to the hospital while the engine goes back into service. For BLS level calls, both engine and squad will go back into service while the BLS ambulance transports.


Thanks for the info:
The answer, as said above, is documentation.

Start with your PCR as stated above. Include all FD vital signs in the record as PTA followed by your readings en route. Detail your concerns in a factual manner: no BGL at scene; no 12-lead at scene. Avoid documenting any opinions; they will be discounted. 

Does your company have a UO (unusual occurrences) process? If so, I would go there next. Document each UO in detail and submit to your company rep. These should include incident number, date, fire crew and a detailed narrative. You would do well to have your language closely follow that of your local protocols so that deficiencies are clear. Keep digital copies for yourself. 

My only concern with going right to County EMS is that it jumps so many logical steps. Your employer has a vested interest in BLS units not transporting ALS pts without a medic. If FD is shorting the process and creating a dangerous situation with significant liability potential, your employer is the one that needs to bring this forward. 

If you provide enough information and they choose not to do anything, then one of the following is clear:
1. They are choosing to ignore it (find a new employer)
2. You are overreacting. 

Going off the farm as a rogue reporter will cause problems for you unless you at least try the path detailed above.


----------



## Chris31 (Nov 29, 2014)

Keep in mind, the 911 contract is a lucrative venture for private companies. That being said, LA County Fire has a large say in choosing which companies get the contracts when bidding comes around, based on their experiences with each respective provider.   These private companies, mine included, do everything they can to schmooze fire and throw bbq's for on-duty crews, suspend employees on firefighters complaints, and especially, turn a blind eye to fire's transgressions. Our company is well aware of the issues I brought up, as well as a severe lack of professionalism displayed by fire towards us. They even go as far as to encourage us to practice out-of-scope procedures (glucose sticks) at fires request, just to keep them happy. It's a major conflict of interest.


----------



## gotbeerz001 (Nov 29, 2014)

Chris31 said:


> Keep in mind, the 911 contract is a lucrative venture for private companies. That being said, LA County Fire has a large say in choosing which companies get the contracts when bidding comes around, based on their experiences with each respective provider.   These private companies, mine included, do everything they can to schmooze fire and throw bbq's for on-duty crews, suspend employees on firefighters complaints, and especially, turn a blind eye to fire's transgressions. Our company is well aware of the issues I brought up, as well as a severe lack of professionalism displayed by fire towards us. They even go as far as to encourage us to practice out-of-scope procedures (glucose sticks) at fires request, just to keep them happy. It's a major conflict of interest.


This is why I was saying give them a chance to bring it forward. If you file a complaint without your employer knowing and they find out, you will end up getting fired.


----------



## CentralCalEMT (Nov 30, 2014)

The best advice for saving your own behind if something goes wrong is document, document, document. If it did not happen, it did not happen. If it happened, it happened. Do not lie or cover up for fire. If things go bad, do you think they will cover for you? It is unfortunate to hear you all are still mistreated down there. It sounds like nothing changed from when I left there years ago. 

As far as voicing grievances, it is unfortunate that you work in LA county. The issues you expressed above have been happening there for decades. Remember, the sad fact for companies is that the first priority is keeping the fire department happy and the second priority is patient care. It is wrong. I got my start in EMS working in LA County so I know first hand how it is. Probably about a decade ago, when I was an EMT down there, a certain fire department sent a patient with me BLS. He was ETOH and confused. According to fire, other than the intoxication, the only other complaint was the a patient had a 1 inch laceration to his neck which had been bandaged by copious amounts of kerlex prior to my arrival. The patient went unresponsive enroute to the hospital so I diverted to a closer hospital (which happened to be a trauma center), rather than the one requested by the patient's friend. It turns out the patient had 6 STAB WOUNDS to his neck and internal injuries from blunt force trauma. I reported the incident and almost lost my job. I was told that I should have not diverted to the hospital 90 seconds away, but rather pulled over, and called ALS back to reassess the patient. ALS would have been several miles away by then if they even made it back to quarters before another call and we were mere blocks from a level 2 trauma center. My boss went so far to write me up for disobeying a fire department request and stated that even when fire ships a patient BLS we are not to reassess the patient and by doing that I put the patient at risk because a paramedic has more knowledge than me. He said they have a contract to fulfill and need to not make the fire department look bad. Does that type of situation sound familiar to you?

My hat off to you for trying to stand up for the right thing and be a patient advocate. If it becomes unbearable down there, consider a move to a different county. When I became a paramedic, that is exactly what I did. It is a big move, but if you want to work in a system where your partner is a paramedic and your unit has the final say in patient care and patient destination, and BLS fire departments that support you on scene and do not look down on you, consider moving to Kern or Tulare Counties to work.


----------



## Jim37F (Nov 30, 2014)

CentralCalEMT said:


> The best advice for saving your own behind if something goes wrong is document, document, document. If it did not happen, it did not happen. If it happened, it happened. Do not lie or cover up for fire. If things go bad, do you think they will cover for you? It is unfortunate to hear you all are still mistreated down there. It sounds like nothing changed from when I left there years ago.
> 
> As far as voicing grievances, it is unfortunate that you work in LA county. The issues you expressed above have been happening there for decades. Remember, the sad fact for companies is that the first priority is keeping the fire department happy and the second priority is patient care. It is wrong. I got my start in EMS working in LA County so I know first hand how it is. Probably about a decade ago, when I was an EMT down there, a certain fire department sent a patient with me BLS. He was ETOH and confused. According to fire, other than the intoxication, the only other complaint was the a patient had a 1 inch laceration to his neck which had been bandaged by copious amounts of kerlex prior to my arrival. The patient went unresponsive enroute to the hospital so I diverted to a closer hospital (which happened to be a trauma center), rather than the one requested by the patient's friend. It turns out the patient had 6 STAB WOUNDS to his neck and internal injuries from blunt force trauma. I reported the incident and almost lost my job. I was told that I should have not diverted to the hospital 90 seconds away, but rather pulled over, and called ALS back to reassess the patient. ALS would have been several miles away by then if they even made it back to quarters before another call and we were mere blocks from a level 2 trauma center. My boss went so far to write me up for disobeying a fire department request and stated that even when fire ships a patient BLS we are not to reassess the patient and by doing that I put the patient at risk because a paramedic has more knowledge than me. He said they have a contract to fulfill and need to not make the fire department look bad. Does that type of situation sound familiar to you?
> 
> My hat off to you for trying to stand up for the right thing and be a patient advocate. If it becomes unbearable down there, consider a move to a different county. When I became a paramedic, that is exactly what I did. It is a big move, but if you want to work in a system where your partner is a paramedic and your unit has the final say in patient care and patient destination, and BLS fire departments that support you on scene and do not look down on you, consider moving to Kern or Tulare Counties to work.


I just want to reiterate the document,  document,  document part.

As far as me personally being an EMT in LA County...I'm so glad I work directly for a department as an AO...means instead of a street corner post following the call I go back to the station where my medics are, and after only a couple months have gotten to know most of the crews I work and run calls with, meaning they pretty much trust us to run a BLS assessment as needed. And if there's ever any issues that come up I have an EMS Captain and an EMS Battalion Chief I can go to which should carry just a bit more weight than a private company supervisor when dealing with the occasional arrogant prick paragod (unfortunately even we're not immune to having one or two running around).

If I was allowed to make one single change it would be to put the private ambulances in the same stations as the squads they run with.

Either that or have the ambulances be medic/basic so even if fire insists it's BLS and they leave there's still a medic available if the EMT isn't quite comfortable running the call themselves.


----------



## DrankTheKoolaid (Nov 30, 2014)

Ah the reason California has such crappy protocols..... The ever famous LAFD..

Nothing like a fire Union to sweep crap under the rug and cover for sub standard practitioners. 

Yes I understand most did not go into the fire service to become medics and EMTs, but guess what due to the absolutely excellent fire prevention people FF are 95% or greater medical responders and 5% dumpster firefighters. 


My rural brethren excluded....


----------



## socalmedic (Nov 30, 2014)

As others have said, it hasn't changed much in the 7 years since I left. I had been sent BLS on patients with multi-system trauma, penetrating trauma to the trunk, chest pain that ended up being STEMI.... you name it and LAclownyFire has sent it BLS. I now work as a paramedic in a neighboring county near the border and every other day or so the BLS provider rolls in with an ALS patient and no paramedics. The hospital here is not okay with how LAcoFD operates and the Pre-Hospital Lesion Nurse filed numerous reports with not only their BC/EMS division, but the base hospital who is their med control, and the county EMS agency with no apparently no changes (this is not to say nobody was disciplined or addressed as we dont get that information).

my suggestion is to document in your PCR, and your own record because somehow when the poop flies even ePCRs "get lost". document only factual observations, opinions can discount your entire report. Email your reports, use the EMS Sequence number not the patient name, to the base hospital paramedic lesion nurse, the medical control physician for their base (you can look them up on the LAEMS website), and CC the EMS agency (call them to find out who their CQI person is) request a confirmation that they received the notification.

here is the policy MANDATING at 3 day reporting window for the PCC. (policy 214)
http://file.lacounty.gov/dhs/cms1_206170.pdf

further you can contact their investigator directly
*Kurt Kunkel*
Civilian Investigator
(562) 347-1687
(562) 941-5835 (FAX)KKunkel@dhs.lacounty.gov

he is the person who posted the thread to the "anonymous" reporting line. It appears that he is more interested in company violations for all the BLS companies in the county, but he could probably put you in touch with the right person to report issues of ethics and patient care. just remember that CPF or IAFF gets involved when any fire fighter is disciplined and once they get the report you will not by anonymous anymore because the firefighter has the right to face his accuser.

I hope everything gets better in LA sooner rather than later, because it has been going downhill for years.


----------



## COtoWestAfricaMEDIC (Nov 30, 2014)

How come southern cali has not had the big earthquake, and floated off in in the sea away from the US and down to Mexico. The EMS system in southern cali  belongs in Mexico City or wait there's might be better.


----------



## Tigger (Nov 30, 2014)

Jim37F said:


> In addition to the above, use your PCR's to document EVERYTHING. If you have to write in your narrative that you felt the patient should have gone ALS but was only sent BLS, write it. If no 12 lead was done, and you believe it was indicated, Write no 12 lead performed on scene, etc etc etc. Don't just write LACoFD, be specific which squad and engine were on scene with you. Do the same when giving your handover report to the hospital. Tell the nurses exactly why you think the patient should be ALS, what the medics on scene did and did NOT do. Make your official reports to the County FD HQ, your company, and the County EMSA. But in the immediate meantime, care as best you can for the patient you have, don't be afraid to say you need to divert to the SRC/ASC....if you can, learn the phone numbers to the local hospital EDs or even the base station if need be.



You're PCR is not the place to discuss which treatments _you feel _should or should not have been performed. PCRs are a record of the care provided, and that it's it. If there is a problem on a call it should be documented on an incident report, not a patient's medical record.


----------



## socalmedic (Nov 30, 2014)

Tigger said:


> You're PCR is not the place to discuss which treatments _you feel _should or should not have been performed. PCRs are a record of the care provided, and that it's it. If there is a problem on a call it should be documented on an incident report, not a patient's medical record.


I respectfully disagree. firstly, the BLS report in LA County does not get attached to the patients chart; the report from the ALS agency is taken with the patient (they are still using paper carbon copies) and it is placed in the chart. the BLS PCR is used for billing. Secondly, documenting discrepancies is a vital part of the health record. physicians and nurses document discrepancies all the time which is useful for the final provider to discern validity of findings. as a permanent and official record the PCR is how investigators will determine what actually happened. it should be noted that 12-leads are not transmitted in LA county, printed 12-leads are only collected on patients transported as ALS and even then rarely make it into the patient chart if it wasn't a STEMI.  lets look at a case example:

55 year old female C/O Chest pain calls 911. ALS decides this isnt a "real chest pain" and decide this is bls with no BGL or 12 lead. patient has a Hx of angina, diabetes, and peripheral neuropathy. ALS makes base contact because they need approval to send this as BLS and report exertional pain in the shoulder, BGL 120 mg/dl, and a - 12-lead. the BLS provider was on scene for the entire assessment and knows that there was no BGL check and no 12 lead performed. when you get to the non-PCI hospital they find a bgl of 400 mg/dl and a STEMI on 12-Lead. they have to keep the patient for an hour until a CCT ambulance arrives to transport the patient 5 min away to the PCI hospital. the patient dies and the family sues.

-if the emts dont document in the PCR what they actually saw the only records will be the falsified ALS report and the hospitals charts. because the ALS report shows that the assessment was done correctly it will be chalked up to an "evolving MI" and that will be the end of the investigation.
-if the emts do document that they witnessed no 12-lead and no BGL check, and they were on scene the entire time ALS was there will be an investigation as to what is correct. if the investigation moves quick enough the investigator can download the memory from the monitor and verify if there was ever a 12-lead done at the date and time in question, and check the glucometer to see if there is a record for a BGL at the date and time in question. given that there is a requirement to report adverse outcomes within 72 hours both machines should still have all the data needed still in the memory.


----------



## triemal04 (Dec 1, 2014)

Tigger said:


> You're PCR is not the place to discuss which treatments _you feel _should or should not have been performed. PCRs are a record of the care provided, and that it's it. If there is a problem on a call it should be documented on an incident report, not a patient's medical record.


It isn't the place to mention what you thought should have been done...most of the time.  

If an EMT requests that an eval be done by a paramedic, and is refused, either by the paramedic, or by another EMT who is in overall charge, that should definetly be documented.  That's more than appropriate, if only for CYA purposes, and there's nothing wrong with putting it in the chart; makes it clear to anyone down the road in the hosptial what was/wasn't done.

Listing things that weren't done...if you know for a fact that something should have been, or was reported to have been done but wasn't, it's still appropriate to document that as well.  Just be sure that you aren't listing things that weren't indicated; the only effect will be to make you look silly.


----------



## MonkeyArrow (Dec 1, 2014)

I agree with documenting the lack of appropriate care in the PCR. As an EMS provider in the field, that is the only protection you have against erroneous claims or lawsuits. What do you think the first thing a lawyer is going to say in court when he is suing you for malpractice? "If you had thoughts that this patient did not need to go BLS, why is there no record of this? Are you now lying or were you negligent in the care of this patent." If you're getting screwed over, you do what you need to do save your butt. If that means you document what has happened/did not happen in the PCR, then you do so. At the end of the day, it is your license to practice on the line.


----------



## terrible one (Dec 2, 2014)

My advice, move far far away from LA county (CA as a whole really). 

In all seriousness I witnessed much of the same in LA county for several years. Most fire depts are delusional in the fact that they perform poor care. They'll never admit it and I highly doubt it'll ever change. Obviously this problem is not a fire only issue, but I've seen privates much more proactive in either training or disciplining poor patient care paramedics / EMTs.


----------



## socalmedic (Dec 2, 2014)

terrible one said:


> My advice, move far far away from LA county (CA as a whole really).
> 
> In all seriousness I witnessed much of the same in LA county for several years. Most fire depts are delusional in the fact that they perform poor care. They'll never admit it and I highly doubt it'll ever change. Obviously this problem is not a fire only issue, but I've seen privates much more proactive in either training or disciplining poor patient care paramedics / EMTs.



Much of this also has to do with Sovereign Immunity, municipalities cannot be held liable in civil court for negligence so there is no motivation for the county to ensure their paramedics are competent. however the private companies do not have this protection and can be sued for lots of money if their paramedic commits a negligent act, there is a lot of financial motivation for the privates to ensure their paramedics are competent and following the rules.


----------



## Christopher (Dec 2, 2014)

titmouse said:


> Well thats what happens when you have fire medics,  most of them hate the ems side of the job but they have to do it because theyre required. The sad part is that in the end the ones that suffer are the patients.


Yes, us Fire Medics are certainly the problem facing EMS  Just because California is backwards/backwater when it comes to EMS doesn't mean the rest of us are.


----------



## terrible one (Dec 2, 2014)

Christopher said:


> Yes, us Fire Medics are certainly the problem facing EMS  Just because California is backwards/backwater when it comes to EMS doesn't mean the rest of us are.



I agree. Even in CA there are great FDs with amazing employees. However, this is not the norm and I've worked in 5 different counties with close to over 30 different fire depts. 
The apathy towards EMS is palpable. Good to know there are some FDs out there that do actually care though.


----------



## Christopher (Dec 2, 2014)

terrible one said:


> I agree. Even in CA there are great FDs with amazing employees. However, this is not the norm and I've worked in 5 different counties with close to over 30 different fire depts.
> The apathy towards EMS is palpable. Good to know there are some FDs out there that do actually care though.


The system is what matters. Strong QA/QI, quality education, with empowered providers given the responsibility to provide high quality care; the keys to success are not dependent on the delivery model.


----------



## Tigger (Dec 2, 2014)

MonkeyArrow said:


> I agree with documenting the lack of appropriate care in the PCR. As an EMS provider in the field, that is the only protection you have against erroneous claims or lawsuits. What do you think the first thing a lawyer is going to say in court when he is suing you for malpractice? "If you had thoughts that this patient did not need to go BLS, why is there no record of this? Are you now lying or were you negligent in the care of this patent." If you're getting screwed over, you do what you need to do save your butt. If that means you document what has happened/did not happen in the PCR, then you do so. At the end of the day, it is your license to practice on the line.



Document it elsewhere than a medical record, that's pretty much exactly what an incident report is for. 

If the system is so broken that this isn't adequate, well I don't know what to say then. Maybe this is the only way you deal with that, though it doesn't make it the right way. Socal's post highlighting how messed up the record keeping is disconcerting at best.


----------



## avdrummerboy (Dec 4, 2014)

Funny how LACo was the first county to have paramedics and it has changed (or even gone backwards) the least. Anyone who has seen the ALS protocols knows how ridiculous they are, anyone who's worked BLS there knows how stupid it can be, the best you can do is document. Not just PCR'r, IR's as well. Also, there is nothing wrong with documenting what mandatory things didn't happen on scene. I don't know of any ALS system that doesn't require a 12 lead on chest pain calls, if it's not done (especially if someone calls it in saying that it was) make damn sure that you document that. It doesn't matter that you're BLS, what did or did not happen in your presence is important to document.


----------



## gonefishing (Dec 4, 2014)

avdrummerboy said:


> Funny how LACo was the first county to have paramedics and it has changed (or even gone backwards) the least. Anyone who has seen the ALS protocols knows how ridiculous they are, anyone who's worked BLS there knows how stupid it can be, the best you can do is document. Not just PCR'r, IR's as well. Also, there is nothing wrong with documenting what mandatory things didn't happen on scene. I don't know of any ALS system that doesn't require a 12 lead on chest pain calls, if it's not done (especially if someone calls it in saying that it was) make damn sure that you document that. It doesn't matter that you're BLS, what did or did not happen in your presence is important to document.


You know the average emt makes what Johnny and Roy were making lol. I caught their pay in one of the episodes I think it was $8.25 an hour as a parmadeic fire fighter.  Average emt is $9 an hour lol sad but true.


----------



## Bullets (Dec 4, 2014)

Question regarding LA

When ALS arrived, you give a report and legally transfer care to them. When they decide it is a BLS patient, can you refuse to accept the patients care? I dont know if this is how they look at it in LA, and i dont know if you want to makes waves of this size, but if you really feel that this patient needs advanced levels of care, then just refuse to accept the patient from them


----------



## Jim37F (Dec 4, 2014)

Bullets said:


> Question regarding LA
> 
> When ALS arrived, you give a report and legally transfer care to them. When they decide it is a BLS patient, can you refuse to accept the patients care? I dont know if this is how they look at it in LA, and i dont know if you want to makes waves of this size, but if you really feel that this patient needs advanced levels of care, then just refuse to accept the patient from them


Ideally that's the case. When I worked for Gerber Ambulance in Torrance, TFD responded to medicals using the same model as LACoFD, and when they sent a couple medics to our Gerber new hire orientation class they maintained that we were able to do that....fortunately I never had to do that out in the field, but I got the sense that some medics would've ALS'd no problem in that case, and others would have made a big fuss the way the OP describes...seems very individual personality based.

Hopefully (and I say this wanting to become an LACo FF, but then again I want to be a medic who occasionally gets to put out a fire or cut apart a car as a perk lol) the advent of ePCR's will make QA/QI easier and calls more transparent (at Glendale our ePCR software wont close out the form and let you upload it if you don't have a 12 lead attached to your chest pain run form, so you better get one, or explain why you have a picture of nothing attached instead).


----------



## gonefishing (Dec 4, 2014)

Jim37F said:


> Ideally that's the case. When I worked for Gerber Ambulance in Torrance, TFD responded to medicals using the same model as LACoFD, and when they sent a couple medics to our Gerber new hire orientation class they maintained that we were able to do that....fortunately I never had to do that out in the field, but I got the sense that some medics would've ALS'd no problem in that case, and others would have made a big fuss the way the OP describes...seems very individual personality based.
> 
> Hopefully (and I say this wanting to become an LACo FF, but then again I want to be a medic who occasionally gets to put out a fire or cut apart a car as a perk lol) the advent of ePCR's will make QA/QI easier and calls more transparent (at Glendale our ePCR software wont close out the form and let you upload it if you don't have a 12 lead attached to your chest pain run form, so you better get one, or explain why you have a picture of nothing attached instead).








Sorry couldn't help it.....lol


----------



## Jim37F (Dec 4, 2014)

gonefishing said:


> Sorry couldn't help it.....lol


Doesn't help that the ambulances are the same color scheme, blue and yellow "Blellow!"


----------



## OG EMT (Dec 5, 2014)

Bullets said:


> Question regarding LA
> 
> When ALS arrived, you give a report and legally transfer care to them. When they decide it is a BLS patient, can you refuse to accept the patients care? I dont know if this is how they look at it in LA, and i dont know if you want to makes waves of this size, but if you really feel that this patient needs advanced levels of care, then just refuse to accept the patient from them





Bullets said:


> Question regarding LA
> 
> When ALS arrived, you give a report and legally transfer care to them. When they decide it is a BLS patient, can you refuse to accept the patients care? I dont know if this is how they look at it in LA, and i dont know if you want to makes waves of this size, but if you really feel that this patient needs advanced levels of care, then just refuse to accept the patient from them


In L.A. County Protocol for one pre-hospital team handing a patient off to another, i.e. County Fire Squad handing patient off to EMT Unit for BLS transport, the receiving team must agree to accept patient care. Now if you're going to insist that they follow up with patient they feel only needs BLS you better have a good reason, and stick to your guns. I have never had a County Fire Squad refuse, some took it in good heart some went into door slamming mode. Document everything.


----------



## socalmedic (Dec 7, 2014)

Bullets said:


> Question regarding LA
> 
> When ALS arrived, you give a report and legally transfer care to them. When they decide it is a BLS patient, can you refuse to accept the patients care? I dont know if this is how they look at it in LA, and i dont know if you want to makes waves of this size, but if you really feel that this patient needs advanced levels of care, then just refuse to accept the patient from them



Technically they aren't transferring care to you, technically when they made base contact the base station MICN (radio nurse) accepted the patient until they arrive at the destination hospital. If they send you BLS the paramedic is no longer responsible because the MICN in on the hook, its kind of a limbo state gray area. It is important to note that once contact is made the paramedic is supposed to re-contact to get any treatment directions (patient went into V-Tach... hang on while I call the hospital...)

while I never met a Paramedic who wouldn't go with you if you asked, as stated above they will go into door slamming mode, I even had one ride in the front once, and you will probably get an earful from the captain and your supervisor for questioning a paragod.


----------



## Jim37F (Dec 7, 2014)

socalmedic said:


> Technically they aren't transferring care to you, technically when they made base contact the base station MICN (radio nurse) accepted the patient until they arrive at the destination hospital. If they send you BLS the paramedic is no longer responsible because the MICN in on the hook, its kind of a limbo state gray area. It is important to note that once contact is made the paramedic is supposed to re-contact to get any treatment directions (patient went into V-Tach... hang on while I call the hospital...)
> 
> while I never met a Paramedic who wouldn't go with you if you asked, as stated above they will go into door slamming mode, I even had one ride in the front once, and you will probably get an earful from the captain and your supervisor for questioning a paragod.



So what if they never made base contact? Not exactly the MICN's patient at that point...even if they call base and get permission to release to BLS, it's still my patient, I'm the attendant doing my reassessment with my patient physically in front of me not the nurse sitting in a radio room at a hospital I may not even be going to.


----------



## socalmedic (Dec 7, 2014)

Jim37F said:


> So what if they never made base contact? Not exactly the MICN's patient at that point...even if they call base and get permission to release to BLS, it's still my patient, I'm the attendant doing my reassessment with my patient physically in front of me not the nurse sitting in a radio room at a hospital I may not even be going to.



first question, if they never made base contact they are operating outside their scope of practice and cannot release to a lesser medical authority. second question, kind of that's why I said its a state of gray area limbo, yes you are the person with the patient but the MICN is still responsible until you arrive at the destination. think of a patient in the ER who is taken by the X-Ray tech for an X-ray. the patients nurse is still responsible for the condition of the patient even though the patient is in a different area of the hospital, but the tech is responsible to let the nurse know if there are any apparent changes in the patient condition or if the patient is not stable enough to go without the nurse.


----------



## Angel (Dec 7, 2014)

Is this a socal thing? Where I work its not the nurses or even the hospitals patient until the patient is physically there and report is given. if thats the case why not just drop the pt off and leave? (its abandonment)
Also they have no choice but to accept the patient if they have the resources to treat him/her.


----------



## Jim37F (Dec 7, 2014)

Really? They have to make base contact to send a patient BLS? Where in the County policy/protocol does it say that? I'm legitimately curious, I've never heard that, and I guess pretty much every medic I've worked with has been in violation for triaging to BLS with Base Contact Not Attempted checked off on the run form.


----------



## gonefishing (Dec 7, 2014)

Jim37F said:


> Really? They have to make base contact to send a patient BLS? Where in the County policy/protocol does it say that? I'm legitimately curious, I've never heard that, and I guess pretty much every medic I've worked with has been in violation for triaging to BLS with Base Contact Not Attempted checked off on the run form.


I second that.lol


----------



## socalmedic (Dec 7, 2014)

Jim37F said:


> Really? They have to make base contact to send a patient BLS? Where in the County policy/protocol does it say that? I'm legitimately curious, I've never heard that, and I guess pretty much every medic I've worked with has been in violation for triaging to BLS with Base Contact Not Attempted checked off on the run form.



I must make a public apology and redact my prior statement. 

It seems that policy 808 has changed it appears in 2013, that there is now a list of patient complaints (albeit, most complaints) which require base contact. there are also Standing Field Treatment Protocols (SFTP), however LAcoFD is not authorized for SFTP (according to policy 401). my statement should say that on any patient where an ALS tool has been used in the assessment or a complaint listed in policy 808, or if the agency is authorized to use SFTP and the protocol indicates base contact the paramedic must make base contact and get authorization for BLS transport. or if the paramedic unit is assigned to an area utilizing the "Round Robin" or the call is within the former catchment of a closed MAR, the designated Base must be contacted for destination both ALS and BLS.

one other exception I found, if you are on Catalina island and the only helicopter the MAC could dispatch was the USCG who has only a rescue swimmer you are allowed to transfer care to them without calling the base...

I don't think I have read these policies in quite some, I apologize for the misinformation.


----------



## Chris31 (Dec 8, 2014)

It should also be noted that out of the 10+ hospitals in our area which we transport to, only about 3 are base contact hospitals... So oftentimes, we are not even transporting to the hospital where base contact was made.


----------



## socalmedic (Dec 8, 2014)

Chris31 said:


> It should also be noted that out of the 10+ hospitals in our area which we transport to, only about 3 are base contact hospitals... So oftentimes, we are not even transporting to the hospital where base contact was made.



Thats fairly common, the medic is assigned a base hospital to contact based on their station location. The base hospital will (should) call the destination ER to inform them of your arrival. there are also catchment areas where you contact a particular base depending on your physical location. Its all sorts of messed up.

IMO they should just staff the MAC with call takers and have residents/attendings available to consult with. it would save tons of money by using economies of scale, provide one number to call, and be much more efficient with diversion and updates. they already have reddinet computers in every ER, just send a notification that they are getting a patient... no need to waste the time calling.

for those of you wondering what the MAC is, it is the Medical Alert Center. a big room down at county where you can call if you cant get through to your base hospital. they already coordinate diversions and MCIs, if you need a copter they can get you one... 

http://ems.dhs.lacounty.gov/MAC/MAC.htm


----------



## Bullets (Dec 8, 2014)

socalmedic said:


> my statement should say that on any patient where an ALS tool has been used in the assessment or a complaint listed in policy 808,


I would argue that if a paramedic did his assessment, an ALS tool has been used, because an assessment alone by a paramedic is infact ALS in its scope. So pretty much any time a Medic makes visual contact and takes vitals, (which should include a BGL and 3-lead) they need to call to release to BLS


----------



## Angel (Dec 8, 2014)

no, because by that logic every call is ALS and they arent. IF 4 lead and BGL are indicated and preformed then I cant release the patient BLS. If they arent and I deem it a BLS call, then guess what. 
What the OP is stating, clearly a medic should be riding a long but he/she isnt which is the issue.


----------



## socalmedic (Dec 13, 2014)

Bullets said:


> I would argue that if a paramedic did his assessment, an ALS tool has been used, because an assessment alone by a paramedic is infact ALS in its scope. So pretty much any time a Medic makes visual contact and takes vitals, (which should include a BGL and 3-lead) they need to call to release to BLS



I am not sure if you are calling the paramedic himself a tool or that his assessment is a tool....

I do not check a BGL and ECG on every patient, there is no reason to be wasting the test strips and stickers if there is no indication.


----------



## JPINFV (Dec 13, 2014)

Also, in a logical world, the determination of EMT or paramedic transport should depend on the outcome of the assessment, not on what tools are used in the assessment. Of course So Cal is such a silly place.


----------



## Jim37F (Dec 13, 2014)

I've never seen a patient here go ALS simply because a 12 lead or a BSG was taken or even an IV started  (though usually they'll only start one on a patient going ALS anyway but starting one doesn't equal automatic ALS transport. Our medics will routinely push 4mg of morphine for pain management , then excluding any other reason for ALS will call base to BLS the otherwise stable trauma patient).


----------



## luke_31 (Dec 13, 2014)

If ALS starts an IV they have to go with the patient.  Granted EMTs can take patients with IVs but only if they are IFTs between facilities or the IV was already present and not started by the paramedics on scene.  If they are giving the morphine and the base hospital is clearing the patient to go BLS the responsibility falls to the base hospital allowing it, but routinely once meds are given the paramedics have to transport.  I was a Los Angeles county paramedic for a few years before I moved on and in all the time I was there, I never saw a single protocol that would have allowed me to start an IV give any medication and then ship the patient BLS.  If anything was to happen to those patients enroute a lot of people including yourself could get into some trouble.  You would probably be ok overall, but you would be dragged into the issue since you were there.


----------



## Tigger (Dec 14, 2014)

Jim37F said:


> I've never seen a patient here go ALS simply because a 12 lead or a BSG was taken or even an IV started  (though usually they'll only start one on a patient going ALS anyway but starting one doesn't equal automatic ALS transport. Our medics will routinely push 4mg of morphine for pain management , then excluding any other reason for ALS will call base to BLS the otherwise stable trauma patient).


That is bad juju.


----------



## SandpitMedic (Dec 14, 2014)

All I can say is... I don't miss CA at all.


----------



## Danner777 (Mar 1, 2015)

That's what the page 2's are for. When there is a transfer of care in the field a page 2 should be done, at least if transferring from als unit to bls unit. The page 2's are submitted to dhs in a certain time frame. That's your chance to throw someone under the bus.


----------



## RedAirplane (Mar 20, 2015)

I lived in LA County (Pasadena) for four years and we had great fire based ambulances staffed with paramedics who really loved the medical side and appreciated us as first responders. 

Then I hear about the rest of the county, and begin to wonder how that system still makes sense to anyone.


----------



## Uclabruin103 (Mar 20, 2015)

This thought process by private ambulance emts is prevalent and perpetuates rumors. Learn your protocols. I used to do the same too, thinking if I heard the word chest pain then it was automatically Omg the big one. When in fact it could be a multitude of non cardiac bls type transports. 

Also where in the protocol does it have to say bgl over 400 goes ALS.  

Yes LA County ems isn't the best in the world as far as protocols go, but you all make it much worse than it really is. There are bad medics everywhere you go.  There's also some great medics everywhere you go


----------



## Uclabruin103 (Mar 20, 2015)

And despite what all the emts are all the private companies say, there's no protocol, outside 516 or whatever the trauma protocol is, with with a specific blood pressure that gets mandatory ALS transport. It's only if they're showing signs of shock. 

LEARN THE PROTOCOLS FOR YOURSELF INSTEAD OF GOING OF WORD OF MOUTH.


----------



## RocketMedic (Mar 21, 2015)

Ucla, the thing is that some assessments are literally impossible without ALS equipment. The OP is talking about the FD blatantly lying about and failing to perform such assessments.


----------



## Jim37F (Mar 23, 2015)

Where are you reading an ALS assessment requires ALS transport? Just because you used a 12 lead and a glucometer to determine the patients complaint is BLS, doesn't mean the medic squad needs to follow the ambulance just because an ALS assessment tool was used. 

Now ALS TREATMENT is a different story...start pushing meds or Edison Medison or invasive bits of plastic, etc. Then yeah, that generally requires the medic squad riding in with the patient (I say generally because our base hospital at least is generally fine with BLSing an otherwise BLS transport minor trauma who got a dose of morphine or an otherwise BLS N/V patient given zofran. That does require base contact and approval first of course)


----------

