# EMT vs. the law



## Spare Luck (Jan 25, 2013)

I work as an EMT in the Bay Area for a private IFT ambulance company (i.e. we do not have a 911 contract with the city). Not long ago, my partner and I were assigned as the stand-by emergency personnel for a fundraiser run. For the most part everything went smoothly until a homeless man came up to us in some distress. It was obvious he had some kind of dysphasia, because his speech was very slurred. I pulled out a pen and paper to communicate and he wrote out "Haldo, need Benadril". The man needed Benadryl, an antihistamine, to counteract an allergic reaction he was having to Haldol, an anti-psychotic. Obviously as a BLS rig I did not have nor could I administer Benadryl so my first thought was load and go especially since the man confirmed he was having difficulty breathing and was profusely salivating. However, as mentioned earlier, our company does not have a 911 contract so we cannot legally transport on-views. We would have to contact city EMS dispatch and get a city rig (or another company with a city contract) to the scene in order to get the man to an ER (legally, that is). Needless to say, I hated being in this position. With a possible airway occlusion imminent, the last thing I wanted on my mind was red tape. 

I'm curious, has anyone else had something like this happen? What did you do? Any advice on how to handle these kinds of situations?


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## CodeBru1984 (Jan 25, 2013)

Spare Luck said:


> I work as an EMT in the Bay Area for a private IFT ambulance company (i.e. we do not have a 911 contract with the city). Not long ago, my partner and I were assigned as the stand-by emergency personnel for a fundraiser run. For the most part everything went smoothly until a homeless man came up to us in some distress. It was obvious he had some kind of dysphasia, because his speech was very slurred. I pulled out a pen and paper to communicate and he wrote out "Haldo, need Benadril". The man needed Benadryl, an antihistamine, to counteract an allergic reaction he was having to Haldol, an anti-psychotic. Obviously as a BLS rig I did not have nor could I administer Benadryl so my first thought was load and go especially since the man confirmed he was having difficulty breathing and was profusely salivating. However, as mentioned earlier, our company does not have a 911 contract so we cannot legally transport on-views. We would have to contact city EMS dispatch and get a city rig (or another company with a city contract) to the scene in order to get the man to an ER (legally, that is). Needless to say, I hated being in this position. With a possible airway occlusion imminent, the last thing I wanted on my mind was red tape.
> 
> I'm curious, has anyone else had something like this happen? What did you do? Any advice on how to handle these kinds of situations?



While I have not experienced the situation that you described above, If I were in your shoes, I would have initiated BLS treatment (as that is what level you are certified to preform at) while awaiting the contracted 911 provider to arrive.


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## DesertMedic66 (Jan 25, 2013)

Same answer as above


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## DrParasite (Jan 25, 2013)

I would have contacted the 911 service for the appropriate unit, as policy, protocol and the law says.

If you thought the patient was critical, transport to the ER or meet an ALS unit enroute. 

If it was me, i would make the request for the 911 service.  and probably start heading to the ER if they were more than 2 minutes out (depending on where the ER was), transporting the patient in my truck.  And if you get reprmianded by your agency, the DOH or whomever, ask them if they would rather have this person die or receive care from a certified BLS provider, who can transport them to definitive care.  Then again, I'm also the type who would frame the write up notice, show it to all my prospective employers (if I get fired), and when they ask why I was terminated, I would stay because I chose to save a guys life, and I can live with my decision.

but that's just me, and I don't work in Ca.


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## medichopeful (Jan 25, 2013)

Sounds more like he needed Epi from the way I read this.


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## NomadicMedic (Jan 25, 2013)

Sounds like he was having a dystonic reaction, not allergic. This wasn't a critical airway issue. (If he knew that Haldol jammed him up, and he knew that he needed Benadryl, it's probably happened before)

At any rate, if my unit was available I would have transported him to the ED or called for another rig to transport. 

I don't understand the problem.


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## JPINFV (Jan 25, 2013)

n7lxi said:


> Sounds like he was having a dystonic reaction, not allergic. This wasn't a critical airway issue. (If he knew that Haldol jammed him up, and he knew that he needed Benadryl, it's probably happened before)




That's what I was thinking.

OP, was there any repetitive head movements?


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## Veneficus (Jan 25, 2013)

Posts like this confuse me...

Assigned to "stand-by" but not permitted to transport?

Were you supposed to treat and release or just call 911?


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## DesertMedic66 (Jan 25, 2013)

I'm not sure how his company works but as for mine we are dedicated to the event so we can't leave. It's all treat and release unless the patient wants/needs to be transported. Then we contact dispatch and we get an ALS or BLS ambulance sent to us code 2 or code 3 depending on what we want. 

However we are also the 911 company. And the events that we go to have to have an ambulance on the grounds at all times or the event must be stopped.


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## Veneficus (Jan 25, 2013)

firefite said:


> I'm not sure how his company works but as for mine we are dedicated to the event so we can't leave. It's all treat and release unless the patient wants/needs to be transported. Then we contact dispatch and we get an ALS or BLS ambulance sent to us code 2 or code 3 depending on what we want.
> 
> However we are also the 911 company. And the events that we go to have to have an ambulance on the grounds at all times or the event must be stopped.



But do you have any capability beyond BLS intervention to actually use to treat and release?


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## jwk (Jan 26, 2013)

DrParasite said:


> I would have contacted the 911 service for the appropriate unit, as policy, protocol and the law says.



This makes zero sense to me.

Does THE LAW actually say they can't transport, or they just don't have a contract to do so?  There's a big difference.


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## DesertMedic66 (Jan 26, 2013)

Veneficus said:


> But do you have any capability beyond BLS intervention to actually use to treat and release?



If any ALS procedure has been preformed then medical direction must be contacted to AMA per county protocol

EDIT: That is just for our small stand bys. For our larger ones we have RNs and Dr.s at the event where 99% is treat and release.


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## AnthonyTheEmt (Jan 26, 2013)

n7lxi said:


> Sounds like he was having a dystonic reaction, not allergic. This wasn't a critical airway issue. (If he knew that Haldol jammed him up, and he knew that he needed Benadryl, it's probably happened before)




Exactly what I was thinking. He doesnt need Benedryl for an allergic reaction. This guy has been around the block a few times and knows that he is most likely having a dystonic reaction, hence the slurred speech.


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## firecoins (Jan 26, 2013)

I am having trouble understanding this.  It is illegal for a private ambulance to transport someone to an ER.  Can this be explained to me?

Is it against the law?  Is it against protocols? It is legal for someone to drive someone to an er in a private vehicle. Why does a private ambulance this become illegal.  

If you get flagged down for a life threatening emergency and the ER is closer than 911 units, you cant transport?


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## Hunter (Jan 26, 2013)

firecoins said:


> I am having trouble understanding this. It is illegal for a private ambulance to transport someone to an ER. Can this be explained to me?
> 
> Is it against the law? Is it against protocols? It is legal for someone to drive someone to an er in a private vehicle. Why does a private ambulance this become illegal.
> 
> If you get flagged down for a life threatening emergency and the ER is closer than 911 units, you cant transport?


 
Agreed, that makes no sense. I work for private IFT right now. If I get a patient who's critical and i'm on a BLS unit, with no ALS available and the hospital being closer, I transport, no if ands or buts. No we don't have the 911 contract, but i'm still in an ambulance, and that' still my patient. our ALS trucks are just as well equipped as 911's trucks so there's no issue there.


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## looker (Jan 27, 2013)

Hunter said:


> Agreed, that makes no sense. I work for private IFT right now. If I get a patient who's critical and i'm on a BLS unit, with no ALS available and the hospital being closer, I transport, no if ands or buts. No we don't have the 911 contract, but i'm still in an ambulance, and that' still my patient. our ALS trucks are just as well equipped as 911's trucks so there's no issue there.



Welcome to California. The company don't have 911 contract must contact 911 or company that is contracted to request permission to transport or have them send a unit. Yes you are an ambulance but you are not emergency contracted provider you can't go code 3 without authorization from 911 dispatch or company that provides 911 services.


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## JPINFV (Jan 27, 2013)

looker said:


> Welcome to California. The company don't have 911 contract must contact 911 or company that is contracted to request permission to transport or have them send a unit. Yes you are an ambulance but you are not emergency contracted provider you can't go code 3 without authorization from 911 dispatch or company that provides 911 services.




That only applies to response, but not transport. Using LACo's policy (since that's the county you work in)...

"Policy:
I. Transport of Patients by EMT Personnel
C. In life-threatening situations (e.g., unmanageable airway or uncontrollable hemorrhage) in which the estimated time of arrival (ETA) of the paramedics exceeds the ETA to the MAR, EMTs should exercise their clinical judgement as to whether it is in the patient's best interest to be transported prior to the arrival of paramedics. "

http://ems.dhs.lacounty.gov/policies/Ref500/502.pdf


It was in the response policy that requires permission from to respond code 3 to locations other than a licensed health care facility (emergent CCT responses), however I can't find that policy online right now.


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## Rialaigh (Jan 27, 2013)

I would probably refuse to stand by at an event as a BLS rig if there was no rig capable of transport at the scene. I mean seriously, aside from CPR and a BVM the biggest asset of a BLS rig is being able to transport more quickly in most places than an ALS rig, take transport away from BLS and what do you have...


In this situation, if the airway is compromised and the PT becomes unconscious I transport, regardless of the law, and I probably still go non emergent. If he stays conscious I wait on a transport truck to get him.


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## wanderingmedic (Jan 28, 2013)

DrParasite said:


> I would have contacted the 911 service for the appropriate unit, as policy, protocol and the law says.
> 
> If you thought the patient was critical, transport to the ER or meet an ALS unit enroute.
> 
> ...



I absolutely agree. Always act in the best interest of the patient and do no harm. I can live with DHS spankings, but I would have an awfully hard time living with myself if I did not do everything I could (within my scope) for a critically ill patient.


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## Handsome Robb (Jan 28, 2013)

n7lxi said:


> Sounds like he was having a dystonic reaction, not allergic. This wasn't a critical airway issue. (If he knew that Haldol jammed him up, and he knew that he needed Benadryl, it's probably happened before)
> 
> At any rate, if my unit was available I would have transported him to the ED or called for another rig to transport.
> 
> I don't understand the problem.





AnthonyTheEmt said:


> Exactly what I was thinking. He doesnt need Benedryl for an allergic reaction. This guy has been around the block a few times and knows that he is most likely having a dystonic reaction, hence the slurred speech.



I agree... Doesn't sound like an allergic reaction to me at all. 



Rialaigh said:


> I would probably refuse to stand by at an event as a BLS rig if there was no rig capable of transport at the scene. I mean seriously, aside from CPR and a BVM the biggest asset of a BLS rig is being able to transport more quickly in most places than an ALS rig, take transport away from BLS and what do you have...
> 
> 
> In this situation, if the airway is compromised and the PT becomes unconscious I transport, regardless of the law, and I probably still go non emergent. If he stays conscious I wait on a transport truck to get him.



We're the same as firefite, if we're the standby rig we don't leave unless there's an extraordinary circumstance (read: MCI at the event). We call for a transport unit, either emergent or non-emergent depending on the situation, assess and treat as needed then pass off to the transport unit. We do hundreds of events per year, they pay a lot of money to have either a BLS, ILS or ALS crew on scene. If we leave to transport they no longer are receiving the services they paid for. They can't just pull a 911 unit to staff that event. The crews at that event are dedicated to it and are either solely special event employees or field employees on OT. 

A compromised airway is one of the few situations in which time is of the essence. If you can't provide the interventions needed to secure that airway you need to get them to someone that can...quickly. I'm not a fan of transporting code 3 but in the situation you described it's very appropriate. Even though transporting lights and sirens doesn't save much time, in a patient that you cannot oxygenate or ventilate, those few seconds may be the difference between walking away neurologically intact or having neurological deficits including being brain dead...An airway compromise that is bad enough to render the patient unconscious is rapidly progressing towards a cardiac arrest.


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## Tigger (Jan 28, 2013)

Robb said:


> We're the same as firefite, if we're the standby rig we don't leave unless there's an extraordinary circumstance (read: MCI at the event). We call for a transport unit, either emergent or non-emergent depending on the situation, assess and treat as needed then pass off to the transport unit. We do hundreds of events per year, they pay a lot of money to have either a BLS, ILS or ALS crew on scene. If we leave to transport they no longer are receiving the services they paid for. They can't just pull a 911 unit to staff that event. The crews at that event are dedicated to it and are either solely special event employees or field employees on OT.
> 
> A compromised airway is one of the few situations in which time is of the essence. If you can't provide the interventions needed to secure that airway you need to get them to someone that can...quickly. I'm not a fan of transporting code 3 but in the situation you described it's very appropriate. Even though transporting lights and sirens doesn't save much time, in a patient that you cannot oxygenate or ventilate, those few seconds may be the difference between walking away neurologically intact or having neurological deficits including being brain dead...An airway compromise that is bad enough to render the patient unconscious is rapidly progressing towards a cardiac arrest.



I agree with most all of your post. If you're doing a standby the ambulance is a means to get you and your equipment to the event. It is not supposed to be for transporting a patient to the ED. 

I say that, but then there is the above scenario. If you are doing a BLS standby and you have unable to oxygenate/ventilate patient, what's the plan going to be? Hopefully not just sitting there monkeying around with a BVM. 

I know I just said that the standby ambulance is not for transport, but in this case it would seem appropriate to violate that rule. 

In any case, that's how we do it at my Sports Medicine job. If we pull a player off the ice that needs the hospital NOW, the paramedic crew dedicated to teams is going to transport. Play will not continue until another standby crew arrives. 

For less serious patients we will stabilize and package the patient until a "regular" 911 unit arrives for transport and then we will just swap stretchers.


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## Rialaigh (Jan 28, 2013)

Robb said:


> I agree... Doesn't sound like an allergic reaction to me at all.
> 
> 
> 
> ...




I'm fine with the lights and sirens transport if you think it's needed in your area. I know in my area I don't think I would save 30 seconds transporting a couple miles going lights and sirens as opposed to non emergent. I probably would not run code, but then again it would really be situational. I would be more likely to run a airway compromise in code 3 in this situation if the patient was a 9 year old, then if the patient is an elderly adult. Again it really all depends on how quickly I think the patient is going to decompensate to the point of cardiac arrest.


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## Christopher (Jan 28, 2013)

Spare Luck said:


> Obviously as a BLS rig I did not have nor could I administer Benadryl...



By whose definition of "Obviously"? That is a bizarre notion to me.


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## Rialaigh (Jan 28, 2013)

Christopher said:


> By whose definition of "Obviously"? That is a bizarre notion to me.



In some states the EMT basic can administer oxygen...can assist with nitro if the patient has it, can give the patient asprin if they patient can take it themselves, and can assist with the patients epi pen....and that is pretty much it....activated charcoal too I think but yeah...thats it...


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## Hunter (Jan 28, 2013)

Rialaigh said:


> In some states the EMT basic can administer oxygen...can assist with nitro if the patient has it, can give the patient asprin if they patient can take it themselves, and can assist with the patients epi pen....and that is pretty much it....activated charcoal too I think but yeah...thats it...



Florida also lets EMTs give glucose gel, oooh...


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## chaz90 (Jan 28, 2013)

Or here in Colorado, EMTs with IV certs can give Narcan and D50. Nebulized Albuterol is available as well. I haven't heard of anywhere that allows Benadryl by BLS.


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## abckidsmom (Jan 28, 2013)

chaz90 said:


> Or here in Colorado, EMTs with IV certs can give Narcan and D50. Nebulized Albuterol is available as well. I haven't heard of anywhere that allows Benadryl by BLS.



Besides which, this guy needs IV benadryl.  Not a BLS skill anywhere I've heard of.  We have a level of EMT, EMT-Enhanced, in VA that would be able to give IV benadryl, but I don't know of a single Enhanced provider who would appropriately recognize and feel confident treating a dystonic reaction.  

I'm not convinced it's a big enough emergency to merit the standby truck doing the transport.  We usually save that for the honest-to-goodness life threats.

I would just do whatever is required to get a transport truck.


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## Tigger (Jan 28, 2013)

Rialaigh said:


> I'm fine with the lights and sirens transport if you think it's needed in your area. I know in my area I don't think I would save 30 seconds transporting a couple miles going lights and sirens as opposed to non emergent. I probably would not run code, but then again it would really be situational. I would be more likely to run a airway compromise in code 3 in this situation if the patient was a 9 year old, then if the patient is an elderly adult. Again it really all depends on how quickly I think the patient is going to decompensate to the point of cardiac arrest.




If your patient has a compromised airway, then the patient has a comprised airway and they need advanced care now, regardless of age.


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## Rialaigh (Jan 28, 2013)

Tigger said:


> If your patient has a compromised airway, then the patient has a comprised airway and they need advanced care now, regardless of age.



Age would make a big difference in how quickly this patient will crash, and how bad the crash will be when it happens. If I can get them to the hospital before they crash running non emergent than I will.


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## abckidsmom (Jan 28, 2013)

Rialaigh said:


> Age would make a big difference in how quickly this patient will crash, and how bad the crash will be when it happens. If I can get them to the hospital before they crash running non emergent than I will.



What kind of crash are we talking about here?  Just wondering.  In my experience, dystonia is a terribly uncomfortable, but completely non-life threatening condition.


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## Rialaigh (Jan 28, 2013)

abckidsmom said:


> What kind of crash are we talking about here?  Just wondering.  In my experience, dystonia is a terribly uncomfortable, but completely non-life threatening condition.



I was thinking airway failure due to allergic reaction. Either way I would be really bummed standing by an event as a non transport BLS....


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## ZombieEMT (Jan 30, 2013)

I am not sure of what the protocols are where you are from, but here in New Jersey an ambulance is an ambulance in the eyes of the state. An IFT that generally only does standby's is the same as a 911 that only does 911. Both have the same requirements for staffing and equipment. If one munic. has a contract for 911 service, that does not mean an IFT can not perform an emergent transport. Many times these events and also certain facilities have contracts with an EMS provider. If dispatch was sending a noncontracted ambulance for an actuall 911 dialed called that would be different. No reason you can not due the transport.

In both the department I work for and volunteer for, we staff an ambulance for all events through the township. If transport is required, it depends on the situation. If the patient is stable and can wait the 5 minutes (or less) for an additional ambulance to do the transport, the standby ambulance will stay and start treatment. If the patient is critical, the standby ambulance will do the transport and the duty rig will cover the standby.


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