# Shady als calls given to bls. How do you deal?



## NorthCalEMT (Nov 27, 2012)

Im in oc and laco and Geez! seems like one shady call after another sometimes, then goes thru a week or so of actual bls calls. I get money is the name of the game for ift companies, and all the blame obviously would fall on the emt, but damn, at least authorize code 3 if vs become worse en route to er for supposed hospital eval. So,my question I wanted to ask what everyone does during those calls... Specifically, how they deal with the nursing home rn's who try and pull the loud, obnoxious or *****ing attitudes when they realize youre onto them? What you say, how you handle, etc? I havr my techniques but i'd like to hear others.

Also, I was wondering... How come ift dispatch/supervisors dont authorize code 3? Does it have something to do with the fact that code 3 would basically mean it should have bern als? I know the rule about transport re: if fire is further to you than it would take to get to nearest hospital u can and should transport.


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## Aidey (Nov 27, 2012)

I have no idea why they don't authorize it, but there is very little evidence that going code has any benefit so don't assume going code 3 would help all that much.


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## mycrofft (Nov 27, 2012)

Hello, thumb-posting police?....


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## JPINFV (Nov 27, 2012)

NorthCalEMT said:


> Im in oc and laco and Geez! seems like one shady call after another sometimes, then goes thru a week or so of actual bls calls. I get money is the name of the game for ift companies, and all the blame obviously would fall on the emt, but damn, at least authorize code 3 if vs become worse en route to er for supposed hospital eval. So,my question I wanted to ask what everyone does during those calls... Specifically, how they deal with the nursing home rn's who try and pull the loud, obnoxious or *****ing attitudes when they realize youre onto them? What you say, how you handle, etc? I havr my techniques but i'd like to hear others.



Simple. Don't engage the SNF RNs. If you need to scoop and run, scoop and run. If you need paramedics, ask to borrow a phone and call 911. You don't have to say who you're calling. 



> Also, I was wondering... How come ift dispatch/supervisors dont authorize code 3? Does it have something to do with the fact that code 3 would basically mean it should have bern als? I know the rule about transport re: if fire is further to you than it would take to get to nearest hospital u can and should transport.



I've never had to request to transport with lights and sirens. I say when start transporting that I am transporting code 3. There's no request about this. They aren't there, they have not examined the patient, and the responsibly for treatment decisions, which includes transport status, lies with the licensed personnel on scene.


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## mycrofft (Nov 27, 2012)

Once the pt is in your car you are responsible. If your company's guidelines bother you, find another. If particular nurses bother you, work somewhere else. 
I'm paraphrasing some of the best advice I was given.


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## NYMedic828 (Nov 27, 2012)

Last I checked the decision to go "code" was mine and mine alone based on my interpretation of the patient's current condition and need for definitive care...


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## DrParasite (Nov 27, 2012)

One you leave the SNF, call for ALS.  You are the highest level of care assessing the patient.  The patient's condition changed from when the nurse was assessing him, and now you need ALS.

call for ALS at the nurses station if you want, but you might deal with a *****y nurse.  If you really want to push the nurse's buttons, ask for her first and last name.  when she asks why, tell her you want to be able to give the information to the family when they sue her personally for the improper treatment they are providing.

while a company may require a dispatcher to "authorize L&S," it's your truck.  if you feel your patient will benefit from L&S, use them.  most of the time the notification to dispatch is made for reports and documentation, and to prevent abuse.  So if you use them, expect to be called into the bosses office to explain WHY you used them.  Many don't want to "authorize" their use due to the potential for liability (and the gross overuse of L&S by responders of all levels), but if you feel it's right, use them; just be prepared to defend your actions.

Lastly, when in doubt, start going to the ER.  don't waste time, take the paperwork and run, and do your best to give notification to the ER that you are bringing in an unstable patient.


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## DesertMedic66 (Nov 27, 2012)

JPINFV said:


> Simple. Don't engage the SNF RNs. If you need to scoop and run, scoop and run. If you need paramedics, ask to borrow a phone and call 911. You don't have to say who you're calling.
> 
> 
> 
> I've never had to request to transport with lights and sirens. I say when start transporting that I am transporting code 3. There's no request about this. They aren't there, they have not examined the patient, and the responsibly for treatment decisions, which includes transport status, lies with the licensed personnel on scene.



Exactly this.


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## Amberlamps916 (Nov 27, 2012)

Welcome to BLS IFT. It happens. Learn to adapt to it, err on the side of caution, and above all have the patient's best interest be your main priority. It wastes time, like JP said, to sit around arguing with the nurses. Most of them think you're just a on call taxi service that will obey all commands because that's what your company's marketers/management promised them. Nothing will change that belief, trust me. They'll sit there and pull the "Well the Doctor said pt needs to go to this hospital 40 miles away BLS blah blah blah. Bottom line, limit your on scene time.

   On a side note, today I found out some interesting information about the recently shut down Medlife ambulance is being investigated for. Apparently, a BLS unit was dispatched from VAN NUYS to a snf in PASADENA for, get this, "POSSIBLE CVA (Ok to go BLS). You would assume that even though they decided to make this call BLS, at least they would have the EMTs transport the patient to the designated stroke center exactly 1 Mile away from the snf. But no, patient was to be transported to an URGENT CARE 14 miles away.
    Upon arrival of the EMTs, they told the facility prior to patient contact that they would be going to the stroke center, regardless of what the doctor who hadn't even seen the patient's presentation said. The nurse told them they can't do that and called the charge nurse. And can you guess what the patient presented as? Left sided facial droop with weak grips and pulls with inability to speak. After getting the patient on the gurney, the charge nurse came with the operations manager of MEDLIFE AMBULANCE on the phone telling the EMTs that if they didn't transport the patient to the URGENT CARE, they would be out of a job. They told him he couldn't do that and transported the patient to the stroke center. They didn't get fired but got written up for "spending too long on scene".

 Apparently both those EMTs reported MEDLIFE AMBULANCE and the snf. Is it any coincidence that the company was shut down soon after? My point is that if you do the right thing, have all your bases covered and be a patient advocate, you can help in getting the companies and facilities that try to pull this kind of crap into the spotlight!
 Good job for being a concerned EMT. We need more of those out there! Keep your head up.


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## fbemt (Nov 28, 2012)

most likely Brighton Convalescent.  Absolute worst nurses, never had any clue what was up with the pt.


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## Amberlamps916 (Nov 28, 2012)

Not sure. The guy who told me about it didn't say where it was. Is that on convalescent row off Fair Oaks? Lol


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## Jon (Nov 28, 2012)

Interesting posts.

When I worked BLS IFT, we'd get sent on some shady runs. Usually the fastest option was to scoop and run. I didn't call for ALS often (because it really delayed more than it helped).

Now I work for a company that requires dispatch document Code 3 response/transport. Especially as a medic, no one questions it, but I better have a good reason.

Every once in a while I'll run hot TO a facility. Usually after calling and getting a good report. Biggest one is the LTAC vent facilities we serve. Even if 911 can get there a little quicker, they have no vent, and no CCT experience - so it's better if we take it.

Usually all I have to do is key up dispatch w/ siren on and they get the message.


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## Anjel (Nov 28, 2012)

If I need ALS for whatever call, I get on my cell, call dispatch, and ALS shows up within ten minutes. 

I've only had to do this a handful of times, but it is usually because when I call the ER with my report they request and intercept. 

I've never gone code with a pt to the ER, unless again the receiving hospital orders it. 

What happens to my patient is my responsibility and my choices. Dispatch doesn't dictate what happens on my truck.


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## firecoins (Nov 28, 2012)

Always used my cell to call ALS when I worked BLS IFT. RN at the SNF does not make the decision.


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## mycrofft (Nov 28, 2012)

Used to be, convalescent facilities would call ambulances to transport people they were sure were dying to shift statistics off them. A couple times  we revived them enroute with basic EMT skills like running an oxygen mask at over 2 LPM.


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## Ewok Jerky (Nov 28, 2012)

As others have said, its my call (and it happens on my cell or radio in the back of the truck).

If a nurse is causing a problem on scene I smile, say thankyou, and bounce.  Once we are out the door its my Pt and I decide the most appropriate facility and priority.  Forget the "best interest of the Pt", if you act like a jerk to a facility, you will get in trouble with the boss.  Remember, the facility, not the Pt, is your customer.

*not saying the best interest of the Pt is not your most important prioirty, but you can still act professionally while on scene, if you want to keep your job*


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## TheLocalMedic (Nov 28, 2012)

Oh man, reading this thread brings back so many memories from my first BLS IFT job!  

If you've worked BLS, then you've undoubtedly run into this situations many times.  Here's a few of my pointers:

*  Remember that your job is mostly about customer service, and the nursing staff are also customers, so play nice with EVERYONE no matter how frustrating they are

*  I always smile and nod a lot, which goes a long way towards making the "*****y" nurses ease up a little

*  Keep nodding an smiling as you completely ignore what "the doctor wanted" and make up your own mind as to whether it's faster to get an ALS unit there or just take the pt directly to hospital

*  Nod and smile some more as the nurse freaks out on you and then explain that you understand their concerns but that you're just "following the rules" and doing what needs to be done

*  If they threaten you or call your company, just nod and smile some more, but state that you don't have time to rationalize or debate with them, and start getting ready to take the pt

*  If you decide it's faster for you to transport, then just get on your horse and ride.  YOU decide if you want to roll code 3, but generally it really doesn't save you much time and it does put you at much higher risk of an accident.  This holds especially true for BLS companies where most employees don't have a lot of experience driving code 3!


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## Tigger (Nov 28, 2012)

We go priority to SNFs and other healthcare facilities all the time. The facilities we contract with call us before 911 9/10 times, we have EMD and enough units to match (if not exceed) the city's response time. We also have ALS units with vents, which none of the 911 services around here have.

Once on scene it's like any other call. If we need ALS, we'll call from the floor and then get moving and intercept on the way or go straight to the ED if it's faster. If the provider in back wants to go to the ED emergent, then we do it. I rarely do this and kindly encourage my partners not too, but at the end of the day the transport priority is solely at the crew's discretion.


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## leoemt (Nov 28, 2012)

Addrobo87 said:


> Welcome to BLS IFT. It happens. Learn to adapt to it, err on the side of caution, and above all have the patient's best interest be your main priority. It wastes time, like JP said, to sit around arguing with the nurses. Most of them think you're just a on call taxi service that will obey all commands because that's what your company's marketers/management promised them. Nothing will change that belief, trust me. They'll sit there and pull the "Well the Doctor said pt needs to go to this hospital 40 miles away BLS blah blah blah. Bottom line, limit your on scene time.
> 
> On a side note, today I found out some interesting information about the recently shut down Medlife ambulance is being investigated for. Apparently, a BLS unit was dispatched from VAN NUYS to a snf in PASADENA for, get this, "POSSIBLE CVA (Ok to go BLS). You would assume that even though they decided to make this call BLS, at least they would have the EMTs transport the patient to the designated stroke center exactly 1 Mile away from the snf. But no, patient was to be transported to an URGENT CARE 14 miles away.
> Upon arrival of the EMTs, they told the facility prior to patient contact that they would be going to the stroke center, regardless of what the doctor who hadn't even seen the patient's presentation said. The nurse told them they can't do that and called the charge nurse. And can you guess what the patient presented as? Left sided facial droop with weak grips and pulls with inability to speak. After getting the patient on the gurney, the charge nurse came with the operations manager of MEDLIFE AMBULANCE on the phone telling the EMTs that if they didn't transport the patient to the URGENT CARE, they would be out of a job. They told him he couldn't do that and transported the patient to the stroke center. They didn't get fired but got written up for "spending too long on scene".
> ...



CVA's are BLS here unless they have airway compromise. Nothing ALS is going to do for a CVA - they need a Stroke center ASAP. ALS is going to delay the time it takes patient to get to definitive care. 

To answer your question - if you need ALS then call them. If you need to run priority then do so. The goal is to get the patient to definitive care using what is in the patients best interest. If ALS would be in their best interest then get them.


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## exodus (Nov 28, 2012)

leoemt said:


> CVA's are BLS here unless they have airway compromise. Nothing ALS is going to do for a CVA - they need a Stroke center ASAP. ALS is going to delay the time it takes patient to get to definitive care.
> 
> To answer your question - if you need ALS then call them. If you need to run priority then do so. The goal is to get the patient to definitive care using what is in the patients best interest. If ALS would be in their best interest then get them.



What they probably need is 911, not a private company though.


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## Anjel (Nov 28, 2012)

exodus said:


> What they probably need is 911, not a private company though.



We are 911 and a private company.


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## leoemt (Nov 28, 2012)

exodus said:


> What they probably need is 911, not a private company though.



Why? What is a 911 call going to do that a private can't? I work for AMR and we run both fire calls and private calls to SNF's. We have the same skills as the engine and aid crews that show up on scene as well as the same equipment. 

The SNF has RN's which are a higher level of care than paramedics. They can provide interventions as well. When I show up on scene I treat the call the same as any other call and make the decisions I have to make. If I need ALS they get ALS.


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## NYMedic828 (Nov 28, 2012)

leoemt said:


> Why? What is a 911 call going to do that a private can't? I work for AMR and we run both fire calls and private calls to SNF's. We have the same skills as the engine and aid crews that show up on scene as well as the same equipment.
> 
> The SNF has RN's which are a higher level of care than paramedics. They can provide interventions as well. When I show up on scene I treat the call the same as any other call and make the decisions I have to make. If I need ALS they get ALS.



Not 100% on this but I believe an RN at a SNF (which are usually not BSNs) can only provide interventions as far as basic CPR and medication administration of prescribed patient meds.

They can't decide to start an IV for example, on a patient without the orders of the overseeing doctor, who in my experience with SNFs, is never present. 

I recognize that technically a paramedic is equally overseen I am not looking to start that debate, it isn't the point im making.



I don't quite understand why private vs 911 is an issue though. A paramedic is a paramedic doesn't matter who they work for. Their experience in treating may vary but thats everywhere...


I am a bit biased in this matter as my opinion of SNF nurses is nowhere near good.


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## TRSpeed (Nov 28, 2012)

leoemt said:


> Why? What is a 911 call going to do that a private can't? I work for AMR and we run both fire calls and private calls to SNF's. We have the same skills as the engine and aid crews that show up on scene as well as the same equipment.
> 
> The SNF has RN's which are a higher level of care than paramedics. They can provide interventions as well. When I show up on scene I treat the call the same as any other call and make the decisions I have to make. If I need ALS they get ALS.



I believe what he means is that they need an immediate 911 unit to transfer the pt not a IFT unit that will have a longer ETA.  But you must work where AMR provides the same level of care for 911 and IFT(I.e. BLS 911). HEre our transfer units are BLS and 911 are ALS. Also AMR btw. So they are different.


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## leoemt (Nov 28, 2012)

NYMedic828 said:


> Not 100% on this but I believe an RN at a SNF (which are usually not BSNs) can only provide interventions as far as basic CPR and medication administration of prescribed patient meds.
> 
> They can't decide to start an IV for example, on a patient without the orders of the overseeing doctor, who in my experience with SNFs, is never present.
> 
> ...



I agree with you about your opinion. However, some of the SNF's we go into are extremely good and have RN's that can do some pretty advanced stuff. However, this is usually because the patient has known needs that require the advanced procedures and doctors have signed off on it. 

I have seen SNF's start IV's and administer meds in the past. I have also seen them contact doctors to get permission. 

That is far and few though and when I arrive I am usually talking to a CNA that is giving me the 1000 yard stare because they understand less than I do.


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## leoemt (Nov 28, 2012)

TRSpeed said:


> I believe what he means is that they need an immediate 911 unit to transfer the pt not a IFT unit that will have a longer ETA.  But you must work where AMR provides the same level of care for 911 and IFT(I.e. BLS 911). HEre our transfer units are BLS and 911 are ALS. Also AMR btw. So they are different.



Your right...here in Seattle AMR provides equal level of care. We are on scene in less than 5 minutes most of the time whether it is a fire call, 911 call or SNF call. Our dispatchers are trained the same as 911 dispatchers and have the same certifications. They triage the calls the same as if you called 911 directly and will send the appropriate units and resources.


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## JPINFV (Nov 28, 2012)

leoemt said:


> CVA's are BLS here unless they have airway compromise. Nothing ALS is going to do for a CVA - they need a Stroke center ASAP. ALS is going to delay the time it takes patient to get to definitive care.




Hypoglycemia is a stroke mimic. 

Paramedics can rule out or treat hypoglycemia. 

Moral of the story is that there's no such thing as a "CVA" until a glucose level has been obtained.


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## Aidey (Nov 28, 2012)

Remember JP, this is King County.... Anything that can remotely be turfed to BLS is.


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## usalsfyre (Nov 28, 2012)

The one problem with all this is that I've often found EMTs are poorly equipped to decide what's "in the best interest" of the average SNF patient.


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## NorthCalEMT (Nov 28, 2012)

Addrobo87 said:


> Welcome to BLS IFT. It happens. Learn to adapt to it, err on the side of caution, and above all have the patient's best interest be your main priority. It wastes time, like JP said, to sit around arguing with the nurses. Most of them think you're just a on call taxi service that will obey all commands because that's what your company's marketers/management promised them. Nothing will change that belief, trust me. They'll sit there and pull the "Well the Doctor said pt needs to go to this hospital 40 miles away BLS blah blah blah. Bottom line, limit your on scene time.
> 
> On a side note, today I found out some interesting information about the recently shut down Medlife ambulance is being investigated for. Apparently, a BLS unit was dispatched from VAN NUYS to a snf in PASADENA for, get this, "POSSIBLE CVA (Ok to go BLS). You would assume that even though they decided to make this call BLS, at least they would have the EMTs transport the patient to the designated stroke center exactly 1 Mile away from the snf. But no, patient was to be transported to an URGENT CARE 14 miles away.
> Upon arrival of the EMTs, they told the facility prior to patient contact that they would be going to the stroke center, regardless of what the doctor who hadn't even seen the patient's presentation said. The nurse told them they can't do that and called the charge nurse. And can you guess what the patient presented as? Left sided facial droop with weak grips and pulls with inability to speak. After getting the patient on the gurney, the charge nurse came with the operations manager of MEDLIFE AMBULANCE on the phone telling the EMTs that if they didn't transport the patient to the URGENT CARE, they would be out of a job. They told him he couldn't do that and transported the patient to the stroke center. They didn't get fired but got written up for "spending too long on scene".
> ...



Good reply! Your right about on-scene time. That story about MEDLIFE is nuts! SNF's might think they're sly, but when my certifications are on the line with certain calls - it's just not worth it. As an EMT-1 going to medic school, any sort of investigation is too risky... not to mention the fact that getting paid about $9/hr (again) isn't worth risking my career. 

Besides that, my partner doesn't handle pressure very well and is a passive, unobservant person by nature. For example, we get a call to pick up an 84 y/o female for a fractured arm and take her about 2 or maybe 3 miles away. We show up, my partner splits to get some vitals while I get the usual info from the nurse. Now, this is where it becomes shady... I ask how she fractured her arm. Response given was "she fell". Next, I asked, when did she fall? only to receive the most suspicious answer(s) I have encountered in a while... "two days ago." I then ask the nurse her history and as I do I notice the patient has Alzheimer's and of course - general weakness. Then I ask if she's been given any medication... answered with a snappy "No! the file is right in front of you with all the answers you need." and as I'm looking through this file I notice norco given for shoulder pain so naturally I point it out and ask if she was given anything today. Anyway, I began suspecting something wasn't right from about 3 minutes into speaking with the nurses, the answer I received and shared here (as well as others I don't wanna bore any of you with), and the fact that the patient was hypertensive (without a history of it). Anyway we bring her to the ER, I give them the facts and relay the information I was given and told by the SNF nurses and long behold... as the cut off her shirt because of the edema was so bad in her right arm (again, no history of any health problems or edema), the RN and the tech gasp. Typically, IMO when ER nurses show an extreme interest in what I'm telling them, and request that I leave the run report (always do anyways) something isn't right. So, the hospital RN asked me again about where we picked her up from and the details of the call... I tell him and he motions me over to look at her shoulder as he's saying how she has a dislocated shoulder and the amount of bruising as well as the edema from the supposed fall couldn't have happened when the SNF said but, must have happened 4 or 5 days ago. Wrapping it up, he said he was calling social services and when I returned about an hour or so later with another patient he was still talking about it with another ER nurse.

Simply amazing what these SNF's get away with and the one with that call... apparently they have a reputation with that hospital for sending their residents with outrages injuries to...

I get that there's a fine line working in IFT with regards to your duty to act, as well as report but, at the same time to take the patient so they get paid. However, $9/hr ...not worth an indefinite ban for a B.S. ALS call passed off to BLS.


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## NorthCalEMT (Nov 28, 2012)

Addrobo87 said:


> Not sure. The guy who told me about it didn't say where it was. Is that on convalescent row off Fair Oaks? Lol



El encanito or something like that in whittier


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## NorthCalEMT (Nov 28, 2012)

Anjel1030 said:


> What happens to my patient is my responsibility and my choices. Dispatch doesn't dictate what happens on my truck.



100% agree. And it may be time for me to look elsewhere for work until medic school starts since I had an interesting conversation with my supervisor today. He basically said: you're new with this company and need to earn the right to rush code 3. followed with: You don't call ALS or report anyone unless going through me first.

That right there my friends... is what I like to say: 'the writing is on the wall'


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## usalsfyre (Nov 28, 2012)

NorthCalEMT said:


> 100% agree. And it may be time for me to look elsewhere for work until medic school starts since I had an interesting conversation with my supervisor today. He basically said: you're new with this company and need to earn the right to rush code 3. followed with: You don't call ALS or report anyone unless going through me first.
> 
> That right there my friends... is what I like to say: 'the writing is on the wall'



We actually have a similar policy. The reason? A huge problem with inappropriate reporting, diversions and utilization by self-rightous inexperienced EMTs....


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## Aidey (Nov 28, 2012)

NorthCalEMT said:


> ... He basically said: you're new with this company and need to earn the right to rush code 3. followed with: You don't call ALS or report anyone unless going through me first.
> 
> That right there my friends... is what I like to say: 'the writing is on the wall'



I'm failing to see the problem with any of this. You're new and the company has policies. What is the problem?


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## NorthCalEMT (Dec 2, 2012)

usalsfyre said:


> We actually have a similar policy. The reason? A huge problem with inappropriate reporting, diversions and utilization by self-rightous inexperienced EMTs....



The problem I have with what was said wasn't as much with the code 3 (although that added to it), but the main issue was when my supervisor said, "you go through me before you report anyone. You only suspected them, you didn't see gross negligence or abuse (i.e. the staff throwing a resident to the floor)". 

So I looked it up because I knew he was wrong. Sure enough ---> I forget the exact wording (and don't want to look it up as this is my last post before I hit the sack) but the law states specified anyone who witnesses or SUSPECTS negligence, or abuse must report it. however, if one person of the party files a written, the other may file via the phone.

That's essentially what I read earlier today again minus certain elaborations.

Long story short... I don't think anyone has the right to infringe on a confidential process like reporting to social services. Worst case scenario... someone unintentionally abuses the system. well, the employer should consider a training regarding form of abuse, etc. Or let's say someone reports frequently and nothing comes from most but, others yield some abuse. I'd say that was well worth it. Besides if SNF's are doing what they're suppose to do especially with our nations most easily victimized and rapidly growing population than who cares if a social worker drops in unannounced to audit or inspect them. who know.... maybe the word might get around to the shadier SNF's that social services has been auditing... I'm sure some of the Shady in those places might get somewhat cleaned up. I view it as a win-win in my above explanation.

I could be completely wrong with my opinion or what I suggest may be illegal. If it is, I welcome the corrections.


P.S. never thought my question would get such a huge response!


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## NorthCalEMT (Dec 2, 2012)

Aidey said:


> I'm failing to see the problem with any of this. You're new and the company has policies. What is the problem?



Code 3 (not too worried)

Reporting- if he was imposing this regarding inexperienced self-righteous emt's I'd understand, would I agree no... however, I'm arguing against that policy on the basis of: the law states witnessed or suspected abuse should be reported. all of which is confidential and my supervisor is attempting to remove the confidential aspect of it.

I know they're a lot of questionable emt's out there and by no means am I the best, but when someone walks like a duck and quacks like a duck it's usually a duck. Being new in this field has nothing to do with being observant and being able to realize when a nurse keeps changing the date of the patients fall. I don't roll to every call hoping to find abuse going on, but when somethings not right + shifty RN answers... not to mention the documentation for the pt was incomplete and didn't add up. For example: pt had no hx of edema however, she had edema in her right arm. RN tried to debate that she had a hx of edema and couldn't tell me why it wasn't in the pt. file going with us to the er.


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## NorthCalEMT (Dec 2, 2012)

Aidey said:


> I'm failing to see the problem with any of this. You're new and the company has policies. What is the problem?



Company policy does not override law. I may be new to this company but I'm not new to knowing when something isn't right especially when it's as obvious as it was with the elder abuse. I cant remember, but If I didn't drop that story in this thread I'll type it up tomorrow for anyone and everyone who is interested to draw their own conclusions. I welcome constructive criticism, advice, and or suggestions.


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## JPINFV (Dec 2, 2012)

usalsfyre said:


> We actually have a similar policy. The reason? A huge problem with inappropriate reporting, diversions and utilization by self-rightous inexperienced EMTs....



The problem with reporting is that if I suspect abuse, then my hands are tied. I. DON'T. HAVE. A. CHOICE. I'm required, by law, to report it. EMTs (at least in California) are specifically mentioned in the mandated reporter law, so this isn't an "including, but not limited to" argument. I don't have a choice to either not report it, or run it through a supervisor. The supervisor isn't mandated to report it, I am. 

/Yes, I've played that game once... unfortunately.


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## JPINFV (Dec 2, 2012)

NorthCalEMT said:


> So I looked it up because I knew he was wrong. Sure enough ---> I forget the exact wording (and don't want to look it up as this is my last post before I hit the sack) but the law states specified anyone who witnesses or SUSPECTS negligence, or abuse must report it. however, if one person of the party files a written, the other may file via the phone.



In California if it's a team, one report can be made for the entire team. In general, there's supposed to be a phone report made within 24 hours and, if I remember correctly, a written submitted within 72 hours. I carried a kit with me with my county's mandated reporter policy (which included how to make reports), a company incident report form, the mandated reporter form, an a preaddressed stamped envelope so that I could complete the process before I even cleared the hospital. 




> Long story short... I don't think anyone has the right to infringe on a confidential process like reporting to social services.


Oh, you think it's a confidential process? How many other crews were treating John Doe at ABC SNF on 12/1/12 at 1300? Heck, how many crews were at ABC SNF on 12/1/12 at 1300?


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## NorthCalEMT (Dec 2, 2012)

JPINFV said:


> The problem with reporting is that if I suspect abuse, then my hands are tied. I. DON'T. HAVE. A. CHOICE. I'm required, by law, to report it. EMTs (at least in California) are specifically mentioned in the mandated reporter law, so this isn't an "including, but not limited to" argument. I don't have a choice to either not report it, or run it through a supervisor. The supervisor isn't mandated to report it, I am.
> 
> /Yes, I've played that game once... unfortunately.



Mandated reporter was the word I was looking for early this morning... and this post of yours states exactly what I was attempting to say in the previous post. Spot on JPINFV


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## NorthCalEMT (Dec 2, 2012)

JPINFV said:


> Oh, you think it's a confidential process? How many other crews were treating John Doe at ABC SNF on 12/1/12 at 1300? Heck, how many crews were at ABC SNF on 12/1/12 at 1300?



Very true! I did think about that. Even though my opinion of my supervisors request to inform him first before reporting are already known... and if my supervisor is imposing the company's will with the reporting either to secure calls or any other reason; because the hospital RN reported it and it was reported roughly around the same time my partner and I were at the SNF, I think it's safe to assume the SNF might "assume" it was us either way. Who knows...? 

I was under the impression it is a confidential process and every attempt is made to keep it that way. So, how does the process work after a report is filed? Does a social worker arrive at the accused/suspected SNF and mention the PT's name from whom the report was filed for? or a time? or do they go off of the information they received 'audit' every aspect of the SNF?


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## JPINFV (Dec 2, 2012)

NorthCalEMT said:


> I was under the impression it is a confidential process and every attempt is made to keep it that way. So, how does the process work after a report is filed? Does a social worker arrive at the accused/suspected SNF and mention the PT's name from whom the report was filed for? or a time? or do they go off of the information they received 'audit' every aspect of the SNF?



I honestly don't know. About a month after it was filed I got a call directly from my company's CEO regarding it and she accepted my reasoning and stated that my story matched my partner's story. A while later I received a letter (I was the primary person on the paperwork, but my partner and I didn't have to each individually report the matter) saying that they were going to do an inspection and that we could go and "observe" but couldn't say anything or ask any questions.


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## hogwiley (Dec 2, 2012)

I can understand why a supervisor might want a new EMT to report the abuse to him. Quite simply most new EMTs dont know enough to know whether what they are seeing is actually abuse or neglect. 

How many EMTs have ANY experience caring for patients in a long term setting? Very few, and they recieve zero training on it either, so they really dont know enough to know any better unless its something fairly obvious, which it rarely is. 

I agree you should be a patient advocate, and its better to error on the side of reporting, but given the lack of training in this area by EMTs, its understandable the supervisor wants to know.


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## Farmer2DO (Dec 3, 2012)

hogwiley said:


> I can understand why a supervisor might want a new EMT to report the abuse to him. Quite simply most new EMTs dont know enough to know whether what they are seeing is actually abuse or neglect.
> 
> How many EMTs have ANY experience caring for patients in a long term setting? Very few, and they recieve zero training on it either, so they really dont know enough to know any better unless its something fairly obvious, which it rarely is.
> 
> I agree you should be a patient advocate, and its better to error on the side of reporting, but given the lack of training in this area by EMTs, its understandable the supervisor wants to know.



No, it isn't.  As said above, it's the law.  The supervisor doesn't get to impose company policy above state law.  Period.  Ever.  They can have a policy where they notify the supervisor that they've reported the suspected abuse through the proper channels (which may or may not be legal to require), but my experience with this type of situation is that the company would prefer to squash these reports before they happen, so that their contracts aren't hurt.  

Again, an EMS supervisor for an ambulance service doesn't supersede the law.


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## exodus (Dec 3, 2012)

TRSpeed said:


> I believe what he means is that they need an immediate 911 unit to transfer the pt not a IFT unit that will have a longer ETA.  But you must work where AMR provides the same level of care for 911 and IFT(I.e. BLS 911). HEre our transfer units are BLS and 911 are ALS. Also AMR btw. So they are different.



That's what I mean


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## Tigger (Dec 3, 2012)

hogwiley said:


> I can understand why a supervisor might want a new EMT to report the abuse to him. Quite simply most new EMTs dont know enough to know whether what they are seeing is actually abuse or neglect.
> 
> How many EMTs have ANY experience caring for patients in a long term setting? Very few, and they recieve zero training on it either, so they really dont know enough to know any better unless its something fairly obvious, which it rarely is.
> 
> I agree you should be a patient advocate, and its better to error on the side of reporting, but given the lack of training in this area by EMTs, its understandable the supervisor wants to know.



I don't know any supervisors with any experience in long term care either. What would a case of non-straightforward abuse or neglect look like anyway?


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## hogwiley (Dec 4, 2012)

> What would a case of non-straightforward abuse or neglect look like anyway?



Well the point was that to someone who hasnt worked around elderly patients in a long term care setting, a lot of things WOULD look like abuse that as it turns out are somewhat normal. The most obvious one being bruises and skin tears. 

I just went on a call recently to a facility where the patient was dehydrated and seemed malnourished. The EMT I was with suggested this was evidence of neglect and said they probably just leave the patient lying there all day and night. The patient had lewy body dementia(among other things), was on an NDD1 diet with honey thickened liquids, and had a braden scale of 9(meaning if you dont properly reposition them every 1 to 2 hours, they get a decubitus ulcer). I asked him if hed ever tried to feed and hydrate a person with severe dementia and that type of diet on a daily basis(nevermind doing the same for 10 other people who probably arent much better off)? In some cases its virtually impossible to keep the person properly hydrated short of using IV fluids or a peg tube or NG. 

I think its tough to uncover abuse in the elderly after the fact. When I worked as a CNA it was something you kind of had to see happen, or in the case of neglect something the oncoming shift could uncover, usually as part of a pattern. Skin breakdown was one warning sign. You can tell when someone had been lying in urine or BM for a long time or hadnt been repositioned or toileted regularly, but had just been quickly cleaned up at the end of a shift. You can check pressure points like heels and knees and ankles to see whether the patients been properly cared for. 

But even skin breakdown isnt always a clearcut sign. Ive seen a decub start on someone because they insisted on sitting in a wheelchair for a couple hours without being repositioned. Another thing a CNA might look at are their toenails, as funny as that sounds. Seems silly but in many cases you have to use a dremel or grinding device(very carefully if they have diabetes) on a regular basis. Or you can sometimes tell if their dentures are taken out regularly or just left in 24 7 by looking at the inside of their mouth. There are a bunch of other warning signs an experienced CNA would spot right off the bat that MIGHT flag neglect, but I doubt even an experienced EMT or Paramedic would notice.


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## hogwiley (Dec 4, 2012)

I should also add the reason CNAs are experts at spotting abuse and neglect, even better than RNs, is because if they dont spot it, it might very well be them who are accused of it. Being falsely accused of abuse was a continuous occupational hazard. 

At the start of every shift we always checked out our people to make sure everything was ok with them, and reported anything that wasnt, if for no other reason than to cover our own A$$.


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## Meursault (Dec 4, 2012)

hogwiley said:


> I think its tough to uncover abuse in the elderly after the fact. When I worked as a CNA it was something you kind of had to see happen, or in the case of neglect something the oncoming shift could uncover, usually as part of a pattern. Skin breakdown was one warning sign. You can tell when someone had been lying in urine or BM for a long time or hadnt been repositioned or toileted regularly, but had just been quickly cleaned up at the end of a shift. You can check pressure points like heels and knees and ankles to see whether the patients been properly cared for.
> 
> But even skin breakdown isnt always a clearcut sign. Ive seen a decub start on someone because they insisted on sitting in a wheelchair for a couple hours without being repositioned. Another thing a CNA might look at are their toenails, as funny as that sounds. Seems silly but in many cases you have to use a dremel or grinding device(very carefully if they have diabetes) on a regular basis. Or you can sometimes tell if their dentures are taken out regularly or just left in 24 7 by looking at the inside of their mouth. There are a bunch of other warning signs an experienced CNA would spot right off the bat that MIGHT flag neglect, but I doubt even an experienced EMT or Paramedic would notice.



Very interesting. What else don't I know about signs of neglect? Any advice on differentiating criminal neglect from acceptable neglect (for SNF patients) and inevitable consequences of disease?


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## Aidey (Dec 4, 2012)

Farmer2DO said:


> No, it isn't.  As said above, it's the law.  The supervisor doesn't get to impose company policy above state law.  Period.  Ever.  They can have a policy where they notify the supervisor that they've reported the suspected abuse through the proper channels (which may or may not be legal to require), but my experience with this type of situation is that the company would prefer to squash these reports before they happen, so that their contracts aren't hurt.
> 
> Again, an EMS supervisor for an ambulance service doesn't supersede the law.



What exactly does the law say though? What is the threshold for reporting? This is where a supervisor may have more knowledge than a brand new EMT. As Hogwiley pointed out, not every little thing is abuse/neglect. Is every skin tear, dirt brief, bruise or fall a reportable incident? What happens if you go to pick up a patient and it is dinner time, and the pt doesn't get to eat, is that neglect? You get the picture. There is a lot of gray area, and someone who doesn't understand what is going and makes a report on could cause a lot of problems without ever understanding that they were the ones who screwed up.


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## CentralCalEMT (Dec 4, 2012)

Let's face it. As mean as it sounds, private BLS IFT companies in LA are NOT EMS organizations because of their management. Granted a lot of the EMTs try their best, but in the end EMS is about the patient. IFT companies are about the profit. Let's take a scenario that is common in LA. 80 year old female with ALOC and weakness. That is triaged as an ALS level response no matter what EMD protocol you use. The sending facility wants the patient not to go to the nearest ER, but to an urgent care across town where the patient's primary care doctor has an agreement with. They can call 911 or a private IFT company.  

911 is notified. They respond within 5 minutes, treat the patient and transport them to the most appropriate receiving facility. The SNF is angry. The primary care MD is angry. The IFT company gets no money. HOWEVER, the patient wins in this scenario. This is real EMS.


IFT companies, on the other hand, will take that same ALS level call, dispatch a BLS ambulance code 2 (because there is no non 911 code 3 BLS response down there) across town in rush hour traffic that takes 45 minutes to get there and transport the patient to an urgent care all because Dr. Quack who has not actually seen the patient wants it. There is little to no QI from LA County EMS agency so it is done completely under the table. The SNF is happy because their patient went where they want. The IFT company is happy because they made $1,000. The ONLY person to lose out is the patient who now has a CVA that is past the window for agressive treatment and the urgent care ends up calling 911 anyway. That is NOT EMS.

The reason why companies do not let their employees call 911, drive code 3, divert, file complaints or do anything else is not because "the supervisor has more experience." Their supervisors do not know what they are doing in general. ALL it is about putting profit over people. If you do not trust your people to be EMTs, why are they working there. It is because they do not want to piss off their cash cow SNFs. With about 75 companies in LA, if you piss off a SNF even while doing the right thing, they will not call you any more. And, there are 74 other "don't give a crap about patient care, give me the money" companies salivating about making more money.


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## Farmer2DO (Dec 4, 2012)

Aidey said:


> What exactly does the law say though? What is the threshold for reporting? This is where a supervisor may have more knowledge than a brand new EMT. As Hogwiley pointed out, not every little thing is abuse/neglect. Is every skin tear, dirt brief, bruise or fall a reportable incident? What happens if you go to pick up a patient and it is dinner time, and the pt doesn't get to eat, is that neglect? You get the picture. There is a lot of gray area, and someone who doesn't understand what is going and makes a report on could cause a lot of problems without ever understanding that they were the ones who screwed up.



Here is a link to California's Mandated Reporter Law for elder abuse:

http://www.sfhsa.org/415.htm

EMS would be included in this law as WHO should report, and WHEN they should report includes: when the victim reports abuse, when the reporter observes abuse, or "When an injury or condition reasonably leads the mandated reporter to suspect that abuse has occurred."

That's it.  There's no provision for having to make sure there  IS neglect, but only that there is SUSPECTED neglect.  It's actually a crime to NOT report it, which could include fines and jail time.  It's not the reporter's job to know if it truly occured, or investigate, or only report the ones that truly are.  If they suspect it, they're required to report it.  The state has their own ways of investigating, and (at least in New York State) trust me, no one is getting an unfair investigation, just because of a report.



CentralCalEMT said:


> The reason why companies do not let their employees call 911, drive code 3, divert, file complaints or do anything else is not because "the supervisor has more experience." Their supervisors do not know what they are doing in general. ALL it is about putting profit over people. If you do not trust your people to be EMTs, why are they working there. It is because they do not want to piss off their cash cow SNFs. With about 75 companies in LA, if you piss off a SNF even while doing the right thing, they will not call you any more. And, there are 74 other "don't give a crap about patient care, give me the money" companies salivating about making more money.



Well said.


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## Farmer2DO (Dec 4, 2012)

hogwiley said:


> I should also add the reason CNAs are experts at spotting abuse and neglect



Experts?  They have college degrees in spotting abuse and neglect? They have specific, formal, documented training in spotting abuse and neglect?  And if they're experts, then they could testify in a court of law about the abuse?


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## hogwiley (Dec 4, 2012)

> Experts? They have college degrees in spotting abuse and neglect? They have specific, formal, documented training in spotting abuse and neglect? And if they're experts, then they could testify in a court of law about the abuse?



You are reading too much into the word expert. I obviously didnt mean CNAs are some sort of forensic experts. But since you mention it, yes, when I was a CNA we had periodic, documented training in spotting and reporting abuse and neglect. It was a big part of both CNA school and the job. Does this mean your typical CNA should be the end all be all reference for what is abuse or not, of course not. 

Obviously there are MANY incompetent CNAs who are far from being experts on anything, but for these people working as a CNA is like walking through a minefield, as there are MANY opportunities as a CNA for someone to effectively and permanently end their medical career through being charged with abuse, either abuse they caused or abuse they tolerated or failed to report. 

Believe me, when your future medical career, reputation, and employment all depend on watching for potential abuse and neglect in people who you are deemed responsible for, you tend to become pretty good at spotting it. Good luck finding a job in the medical field if youve ever been fired from a CNA job for abuse or neglect, regardless of whether the state found you guilty or not, and I witnessed many CNAs fired for exactly that reason. Most of them werent cruel or intentionally abused anyone, but were simply overwhelmed by the job.


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