# To ECG or not to ECG (opinion thread)



## TheGodfather (Dec 31, 2011)

I recently got in trouble for performing [what I feel is] good standard patient care on a patient I had recently. I'll give the scenario(1), my interventions(2), and what my agency's argument against me was (3)

***note: don't get too hung up on the nitty gritty of the patient care/status/etc, that's not the point; I'm going to be really brief***

I work a medic/basic truck.

*1)* Called to a local assisted living center for a 91yo F - "sick person".
ATF pt lying supine in bed, AOx3. staff states she has been not feeling well since the start of the morning (it was now 1300ish) and they would like her to be checked out. Staff also stated patient has been depressed due to a recent loss of mobility.

CC: "not feeling well" -no chest pain, dib, etc.
skin: NWD
Aatent
B: 16 clear bilaterally, non-labored; spo2 96 RA
C: pulse 94, strong radial. 
D: PERRL, intact neuro.
E: afebrile

(these are a rough estimate): 
BP: 146/84 
PR:90-100 Regular 
RR:16NL 
SPO2: 96 RA
BGL: ~110

S: "feels sick"
A: IV contrast
M: too long to list
P: DM, Pacemaker, 2 stents (unknown date), "cardiac", stroke, hyperlipidemia.
L: breakfast x4(ish)hrs PTA (didn't eat much then/recently due to depression)
E: woke up feeling ill

-----------------------------------------

*2)* In a nutshell: IV TKO, blood draw for hospital, BGL, 4-lead, 12-lead (to rule out silent cardiac event--- because she is OLD, FEMALE, and DIABETIC) - 12-lead was normal, nothing worth mentioning.

I deemed this patient BLS, handed off to my EMT-B partner, and drove in without incident/change in status.

----------------------------------------
*3)* My boss told me I was incompetent as a paramedic, and also stated that if I had any intuition of patient being in an acute coronary state, why would I ever let the patient be taken BLS. He stated also that "we just don't do that" (referring to doing quick rule-out 12-leads), and if I were to do that, I should take the patient in everytime....

Last time I checked, BLS caregivers are more than capable of handling calls like that. The practice of performing 12-lead ECGs on the elderly with broad "non-emergent" complaints (IMO) should be done ALWAYS. 

After I described the patient state and what I found on my assessment he said, "you should not have performed the 12-lead, and you should have just let the patient be taken in BLS" ----- ok, now, let's say hypothetically this patient has a silent MI... we just delayed ACLS care 20-30 minutes because we didn't perform a 30 second 12-lead...... In his words, it would be ok to lessen my goal of optimum patient care, to meet standards of "what their standards are" --- this is not okay with me....


Opinions? Am I taking this too critical? Let's hear it!


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## Shishkabob (Dec 31, 2011)

TheGodfather said:


> 91yo F - "sick person".



That's all I need to perform a 12-lead.  






If someone trips and falls and hits their head, but doesn't complain of anything else and is otherwise ok, does your boss require ALS on that as well?  I mean, my God, what if you try to rule out a head injury by asking questions?!  Does he demand a doctor go in the truck if you're transporting from a clinic, too?    If you do no ALS interventions, what's the need for an ALS provider after assessment?



He's either new in his position, incompetent himself, scared of litigation, doesn't trust your agencies EMTs, or real old.


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## DrankTheKoolaid (Dec 31, 2011)

*re*



TheGodfather said:


> I recently got in trouble for performing [what I feel is] good standard patient care on a patient I had recently. I'll give the scenario(1), my interventions(2), and what my agency's argument against me was (3)
> 
> ***note: don't get too hung up on the nitty gritty of the patient care/status/etc, that's not the point; I'm going to be really brief***
> 
> ...





First you were justified in doing the 12 Lead.  Obviously this is not a full report though and based on what you did post no way in hell should this patient be BLS'ed.  

1. You already started ALS interventions by performing the IV start
2. This patient is borderline tachycardic and i would venture to guess one of her many medications rate controller despite her having a implanted pacemaker
3. Loss of mobility" we talking just due to the current illness? If so that just seals the coffin
4. And the 1000 dollar question is!.........  Polyuria, dysuria?   LOL is UTI until proven otherwise.  And like digoxin use UTI is the master imitator and can present as simply as dysuria to complete coma at the other end of the spectrum. And never be fooled by a geriatric patient that is afebrile


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## TheGodfather (Dec 31, 2011)

1)IV maintainence of a saline solution is a BLS skill in my area.
2)rhythm was paced, electrical capture with each complex, no ectopy (im ball parking the rate - it was above 80, lower than 100...i do not remember completely)
3)loss of mobility was 2 months ago; from being old. ---forgot to mention she has history of osteoarthritis.  

why would there be any issue BLSing the patient? i would have done the same interventions that my BLS partner was capable of and trained to do...


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## firecoins (Dec 31, 2011)

12 lead is a must with illness and hx.

Once you did that, its an ALS job that should not be handed over to an EMT to take in. You did the 12 lead and started a line, giving it to an EMT is unacceptable.

Doesn't matter if you did the same exact BLS skills the EMT would do, its an ALS patient.


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## TheGodfather (Dec 31, 2011)

firecoins said:


> 12 lead is a must with illness and hx.
> 
> Once you did that, its an ALS job that should not be handed over to an EMT to take in. You did the 12 lead and started a line, giving it to an EMT is unacceptable.
> 
> Doesn't matter if you did the same exact BLS skills the EMT would do, its an ALS patient.



this is a direct copy from my state protocols:



> Field application/acquisition of 12 lead ECG for transmission only* (Transmission may be defined as direct
> paramedic interpretation and voice communication; automated computer algorithm interpretation, wireless
> transmission and physician interpretation, or any combination of these strategies)



How would what I did be an unacceptable action based on how that is written? I deemed that the patient was not in any type of acute coronary syndrome... how would I then not be able to deem the patient BLS?


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## Devilz311 (Dec 31, 2011)

Not sure how the medical billing works in your state, but once you initiated ALS interventions (IV) it would be billed as an ALS transport.  Had the line not been started, it probably could have been billed as BLS.

We run 2 Medics on our transport trucks, and sometimes answer BLS dispatches.  If a BLS dispatched run for a "sick person" could benefit from fluids or Zofran or any other ALS measure, then it would have to be turned into an ALS chart, and billed accordingly.


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## Devilz311 (Dec 31, 2011)

firecoins said:


> 12 lead is a must with illness and hx.
> 
> Once you did that, its an ALS job that should not be handed over to an EMT to take in. You did the 12 lead and started a line, giving it to an EMT is unacceptable.
> 
> Doesn't matter if you did the same exact BLS skills the EMT would do, its an ALS patient.



Again, this depends on the state.  If we're dispatched as ALS along with a BLS unit, we will more than likely do a 12-lead if the call warrants it.  If in the assessment we find no need for further ALS interventions, we can certainly release the Pt to BLS for transport.

Don't get me wrong, I'm all for finding reasons to treat the Pt instead of finding reasons to release the Pt, but if the Pt is just ill and needs a ride to the hospital, I'm not going to stick them with a $2k bill for a hand-holding ride to the ER.


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## Remeber343 (Dec 31, 2011)

Why in gods name would you ALS if you did a 12 lead???  You use it to rule out, obviously none showed on his 12 lead.  And if his area trains emts in iv maintenance and they are able to competently control rate and flow, why not Bls it?  If they are trained, and his region allows it, it can be Bls. Regardless of what your regions protocols are. That's how things happen in his neck of the woods. Not yours. Plus he's in the front seat if something were to happen, which, the likely hood is slim to none.


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## DrankTheKoolaid (Dec 31, 2011)

*re*



TheGodfather said:


> 1)IV maintainence of a saline solution is a BLS skill in my area.
> 2)rhythm was paced, electrical capture with each complex, no ectopy (im ball parking the rate - it was above 80, lower than 100...i do not remember completely)
> 3)loss of mobility was 2 months ago; from being old. ---forgot to mention she has history of osteoarthritis.
> 
> why would there be any issue BLSing the patient? i would have done the same interventions that my BLS partner was capable of and trained to do...



IV maintainence may be BLS in your area and i would love to read your protocols as i bet that is meant for BLS providers to take transfers.  I would also venture to say that your protocols say a patient must not be transfered to a lower level of care once an ALS intervention is performed (your IV start was ALS as your BLS provider can not do it) read: abandonment.  

And if you do this on a regular basis i would just LOVE to see how it is billed.. Medicare fraud comes to mind if your company bills it as an ALS call when a BLS provider attended


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## TheGodfather (Dec 31, 2011)

Corky said:


> IV maintainence may be BLS in your area and i would love to read your protocols as i bet that is meant for BLS providers to take transfers.




section copied from BLS Skills section:


> IV Maintenance (involves ONLY monitoring and maintenance of previously initiated IV lines as well as
> calculation and adjustment of flow rates - fluids NOT containing any medications or blood products).



as far as the politics of it, abandonment, etc... you may be correct. i will look deeper on it... thank you for the input though! Positive or negative, it still gets my wheels turning! I like seeing things from all angles.


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## Epi-do (Dec 31, 2011)

Where I am at, I would have been taking this patient in, not my BLS partner.  Not so much for the 12-lead, but because of the IV.  (Although, if I felt something warranted taking a look with a 12-lead, I'm not going to hand it over anyway, even if I don't do any additional ALS interventions on the way to the ER.  There was a reason I felt the 12-lead was warranted to begin with.)

BLS providers are allowed to transport patients with IVs and a limited number of fluids/meds for inter-facility transports around here.  If a medic starts an IV on scene, then the medic must transport the patient.

So, with the situation you presented, it doesn't really matter to me what my BLS partner is or isn't allowed to do.  If I felt the need to basically do a full workup on this patient (IV, monitor, dex), I am sitting in the back.  Even if everything checks out ok, there was a reason I felt the need to do everything.


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## Medic Tim (Dec 31, 2011)

To quote Bob Page . If they have a pulse and a problem they get the monitor. I would have done a 12 lead

Is it a policy thing you got in trouble for? I have heard in some areas if you do anythingabove emt scope the pt it the medics. I also know of areas that the Medic can triage the pt to the emts , even after als interventions if the pt is stable and the emts can handle the call.


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## DrankTheKoolaid (Dec 31, 2011)

Medic Tim said:


> To quote Bob Page . If they have a pulse and a problem they get the monitor. I would have done a 12 lead
> 
> Is it a policy thing you got in trouble for? I have heard in some areas if you do anythingabove emt scope the pt it the medics.* I also know of areas that the Medic can triage the pt to the emts , even after als interventions if the pt is stable and the emts can handle the call*.



in Canada or America.  If in America can you post the area so I/We can read the protocols.  As this is considered abandoment in any circle i have ever been in or discussed patient care.  Be it local, state, federal ( USFS ) nowhere have i ever heard of or have read that a ALS provider can give the patient to a BLS provider after an ALS intervention has been performed.   

Emslaw whats your take as a practicing lawyer on this.  Especially if something went wrong and the BLS hadnt noticed it or patient wasnt still on the monitor.


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## STXmedic (Dec 31, 2011)

Corky said:


> in Canada or America.  If in America can you post the area so I/We can read the protocols.  As this is considered abandoment in any circle i have ever been in or discussed patient care.  Be it local, state, federal ( USFS ) nowhere have i ever heard of or have read that a ALS provider can give the patient to a BLS provider after an ALS intervention has been performed.


At my part-time gig (south TX), it's not at all uncommon for the medic to run a 12-lead and then downgrade our pt to our intermediate partner (if we're working with an I; it's usually P/P). And our Intermediates are I85, not I99.


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## DrankTheKoolaid (Dec 31, 2011)

*re*

12 lead aquisition is a rote skill and not ALS.  IV start is ALS, hence my whole discussion in this thread


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## STXmedic (Dec 31, 2011)

Corky said:


> 12 lead aquisition is a rote skill and not ALS.  IV start is ALS, hence my whole discussion in this thread



Ahh, I misread in my skim . Never heard of downgrading to a basic after an invasive procedure has been performed or a medication has been given.


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## EMSrush (Dec 31, 2011)

TheGodfather said:


> In a nutshell: IV TKO



In my region, this would have instantly converted the Pt to an ALS Pt.


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## TheGodfather (Dec 31, 2011)

with the exception of the IV start (shame on me, i will clarify with medical control next time I meet with him) ---- the commotion all boiled down to the 12-lead.... so here is the final question:

As an advanced care provider, is it wrong to perform diagnostic ECGs, interpret, transmit, and deem patient BLS?


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## EMSrush (Dec 31, 2011)

TheGodfather said:


> with the exception of the IV start (shame on me, i will clarify with medical control next time I meet with him) ---- the commotion all boiled down to the 12-lead.... so here is the final question:
> 
> As an advanced care provider, is it wrong to perform diagnostic ECGs, interpret, transmit, and deem patient BLS?



The answer is, it really all depends. It depends on the Pt, the hx, the findings and the comfort level of the BLS provider. There are way too many variables to give this one a simple yes or no answer.


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## TheGodfather (Dec 31, 2011)

EMSrush said:


> The answer is, it really all depends. It depends on the Pt, the hx, the findings and the comfort level of the BLS provider. There are way too many variables to give this one a simple yes or no answer.



DAMN YOU VARIABLES!!!!!!!!! lol

at least the answer wasn't, "NO, you idiot!" -- I guess that is something I can live with


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## DrankTheKoolaid (Dec 31, 2011)

*re*

Not exactly wrong per se.  But earlier you had mentioned not wanting to waste time if it was a cardiac event.  You could already have been enroute while performing the twelve lead saving time.  This patient is obviously going to get a blood draw in the ED for labs.  Instead of looking fror a way to dump your patient on a BLS provider.  Be a patient care advocate and take care of your own patients.  By the time you get to the ED, she could have had the 12 lead, IV and blood draw already done along with a complete history to aid the ED staff in getting things going.

Now this can also be charge and reimbursed as a ALS level call making it worthwhile for your company also


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## WuLabsWuTecH (Dec 31, 2011)

It does really depend on the level of comfort of the BLS provider.  Around here, what you did would have been ok.  Even had you done more medic level interventions, as long as the basic was providing only basic level interventions in the back, then there is no issue.  It still counts as a medic run and you are still in charge however.  At the end of the run, you sign the report.

There are some cases where you need the paramedic to drive for whatever reason, and we are allowed to do that, but it still counts as a medic run.


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## TheGodfather (Dec 31, 2011)

Corky said:


> Not exactly wrong per se.  But earlier you had mentioned not wanting to waste time if it was a cardiac event.  You could already have been enroute while performing the twelve lead saving time.  This patient is obviously going to get a blood draw in the ED for labs.  Instead of looking fror a way to dump your patient on a BLS provider.  Be a patient care advocate and take care of your own patients.  By the time you get to the ED, she could have had the 12 lead, IV and blood draw already done along with a complete history to aid the ED staff in getting things going.
> 
> Now this can also be charge and reimbursed as a ALS level call making it worthwhile for your company also



Makes a lot of sense! I work with a partner who, like me, enjoys providing patient care, so I hate to step on him and take these "normal" appearing patients from him... 12-lead will nearly always be performed (for me at least) either in a non-moving ambulance, or while obtaining history and packaging... but i can see the time wasted with IV starts and fussing about what level of care the patient requires.. good stuff! ill start putting my foot down more on these "iffy" calls... thanks for the input everyone!


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## DrankTheKoolaid (Dec 31, 2011)

WuLabsWuTecH said:


> It does really depend on the level of comfort of the BLS provider.  Around here, what you did would have been ok.  *Even had you done more medic level interventions, as long as the basic was providing only basic level interventions in the back*, then there is no issue.  *It still counts as a medic run and you are still in charge however.  At the end of the run, you sign the report*.
> 
> There are some cases where you need the paramedic to drive for whatever reason, and we are allowed to do that, but it still counts as a medic run.



Sign the report why? If you dont take a run why would you be writing and then signing a chart?  

Care you show us your protocols where it is allowed to hand off a patient to a BLS provider after ALS interventions have been performed.


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## WuLabsWuTecH (Dec 31, 2011)

Corky said:


> Sign the report why? If you dont take a run why would you be writing and then signing a chart?
> 
> Care you show us your protocols where it is allowed to hand off a patient to a BLS provider after ALS interventions have been performed.



I'm sorry, I think we're talking about different things here.  I was under the impression his basic was on his truck and with his department.  In my case, you would sign the report because the truck is still a medic truck even if the medic is not in the back.  There are many times that I have taken a run on a medic truck, even though I am not a medic.  If any medic skills were performed by my partner on scene, generally he will ride and I will drive, but there are times where that may not be the case.  In that case, he remains the in-charge, even though he is not the primary attendant.  If only basic skills were performed, it doesn't matter who is the in-charge on the paperwork.

And gladly:

"2.6.3.6 Paramedics are directed to allow their EMT partners to do as much of the patient care as possible. This includes having the EMT ride in charge"

Please note that in-charge here is defined as being in-charge of the patient care (i.e. the attendant) and not in-charge on the paperwork which is defined as being a medic:


2.6.1.1 Fully Staffed Medic (ALS)
2.6.1.1.1 The minimum crew for (redacted) (ALS) shall be: 1 non-provisional EMT-P with in-charge status, and one non-provisional EMT-B (although EMT-I Preferred).


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## DrankTheKoolaid (Dec 31, 2011)

WuLabsWuTecH said:


> I'm sorry, I think we're talking about different things here.  I was under the impression his basic was on his truck and with his department.  In my case, you would sign the report because the truck is still a medic truck even if the medic is not in the back.  There are many times that I have taken a run on a medic truck, even though I am not a medic.  If any medic skills were performed by my partner on scene, generally he will ride and I will drive, but there are times where that may not be the case.  In that case, he remains the in-charge, even though he is not the primary attendant.  If only basic skills were performed, it doesn't matter who is the in-charge on the paperwork.
> 
> And gladly:
> 
> ...



This still does not say that a patient who has received ALS intervention by a Paramedic with duty to act can be given to the BLS partner.  This just simply says if the call is BLS let the BLS partner get it for the experience is how i read that.

As to the paperwork. Gotcha you mean the medic signs off on your chart...  And does not actually write it him/herself


Side note I love how on the Ohio EMS website they list all the sanctioned people and what the offense punishment was.  California needs to do the same, not just the little bit they do do.   I always love the back of the nursing rags I get how anyone with an RN license that gets in trouble has their name smeared for all to see.  Peer pressure can be a very good motivator to not screw up.


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## medic417 (Dec 31, 2011)

Many services allow basics to do IV's and to even capture ekg.  

Do not forget that an ekg does not rule out a cardiac event, additional testing is required to rule out.  If you feel an ekg is needed as a Paramedic you should probably keep the patient in case it is one of the 50-75% of cardiac events that are not captured on a 12 lead.


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## 18G (Dec 31, 2011)

I think your supervisor was a little harsh in calling you incompetent. 

A 12-lead was certainly warranted but I don't think the call should have been BLS'd. You initiated IV access for a reason. Why? If you didn't feel the patient was all that sick or need IV access for possible deterioration or intervention, than why was an IV started? That is my number one question and I think where other's are coming from also. You must have been thinking in your head this patient may need fluid or a med possibly. And besides the IV you performed another ALS skill which was phlebotomy. Did you send the blood along with the EMT's?    

If you did the 12-lead as part of your assessment and used it as a triage tool and did not perform any other ALS interventions, than I would see where your coming from with downgrading to BLS. 

But once you start down the ALS path you can't hand over to BLS with an ALS intervention in place. Around here we would have had to contact medical command and get the okay to release to BLS.

It doesn't sound like a big deal what happened... just keep it in mind for next time and all is good


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## Handsome Robb (Dec 31, 2011)

You'd get reviewed and dinged here. You preformed an ALS technique. 

"If you're suspicious enough to capture a 12-lead or put someone on the monitor you will attend that patient all the way to the hospital." -Our medical director. 

I might get burned at the stake but I agree with him. Don't dish your partners calls after you started ALS interventions/assessments/techniques, it's not fair to your partner or your patient.


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## Aidey (Dec 31, 2011)

We have both Bs and Is here. If the emt is a B you can't start an IV and hand off the pt, even if it is a lock. With an I you can because it is within their scope. However you can't give meds out side of the I's scope and then hand the pt off. The reasoning is that they can't be expected to monitor the pt for the effects of a medication that isn't in their scope. 

As for the 12 I suspect it would be highly frowned upon by our MD. As other people have said, if you suspect cardiac enough to do a 12 lead you should probably be taking the pt yourself. 

Did the pt have any advanced directives? Where I am at the ekg may or may not have been done based on their level of care status. People on palliative care are limited to palliative measures only, and almost nothing invasive. You can start an IV to give meds, but only if the meds are for the pts comfort. Fluids depend on whether or not they have elected to receive artifical nutrition. So they rarely receive 12 leads unless they are obvious cardiac pts.


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## Handsome Robb (Dec 31, 2011)

Aidey said:


> We have both Bs and Is here. If the emt is a B you can't start an IV and hand off the pt, even if it is a lock. With an I you can because it is within their scope. However you can't give meds out side of the I's scope and then hand the pt off. The reasoning is that they can't be expected to monitor the pt for the effects of a medication that isn't in their scope.



As an Intermediate an also as a medic student who is 2 weeks away from finishing the didactic portion of my class I have to be *really* careful about what medics dish down to me. I have felt pretty comfortable with nearly every patient I have encountered to the point of at least having a general idea or list of differentials. I'm guessing this comes from knowing that I have someone to fall back on if I'm wrong 

All the medics I have worked with have been really good about not dishing me calls however we have had some pretty good discussions about treatment options.


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## Tigger (Jan 1, 2012)

I've seen the above happen where I work in CO before and it's generally accepted. The difference there is that basics can start IVs and hang fluids as well as do blood draws (not done often if ever), so if the 12 lead revealed nothing this patient would often be attended by the basic, which I see no issue with.


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## medic417 (Jan 1, 2012)

Tigger said:


> I've seen the above happen where I work in CO before and it's generally accepted. The difference there is that basics can start IVs and hang fluids as well as do blood draws (not done often if ever), so if the 12 lead revealed nothing this patient would often be attended by the basic, which I see no issue with.



Really?  Again the *12 lead rules nothing out*.  If you suspect cardiac involvement Paramedic needs to keep patient.


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## Outbac1 (Jan 1, 2012)

Oh I am so glad I work in the Great White North. You Americans get so wound up over the letter of the protocol, state rules etc. Fortunatly we have much more leniency here in our interpretation of that stuff. 
 A 91f with that hx, every sunrise is a bonus. My opinion is a proper assessment was done. Maybe the blood and urine tests will show something. Anyone could have sat with this lady on the way to hospital. My question is what was the pacemaker set to run at? Constantly or only if the rate drops below ? number? That info was not likely available on scene. Either way there was no indication of anything bad about to happen. 
 The supervisor was  a) not medically educated, b) scared of lawyers etc. c) concerned about the detailed billing to the pt. You have rules to follow. You don't have to like it but you do have to, at least somewhat, toe the line. Work towards getting bad rules changed. 
 I would imagine there as well as here the highest registered person on the unit is responsible for all the patients all the time no matter who attends. Here we go turn for turn until a pt needs more than my partner can do. Then I will take a call from my partner (a PCP) as required.


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## WuLabsWuTecH (Jan 1, 2012)

Corky said:


> This still does not say that a patient who has received ALS intervention by a Paramedic with duty to act can be given to the BLS partner.  This just simply says if the call is BLS let the BLS partner get it for the experience is how i read that.
> 
> As to the paperwork. Gotcha you mean the medic signs off on your chart...  And does not actually write it him/herself
> 
> ...



The medic might or might not write the chart himself.  There have been plenty of times on a busier run where both me and a medic have been in the back (running a three man crew) and I've written the entire thing only to have her read it and sign it at the hospital.  There have also been times where the medic may have had to drive for whatever reason, and I've been in the back alone on a medic run and he ends up writing the entire thing at the hospital.

That may not be the applicable part of the SOP, I'll have to keep looking, but I know it is allowed because it was covered in my official training and not just something that everyone does and gets away with it.  We were told that it is allowed, but that if the lower level provider ever feels uncomfortable with the situation, then we could refuse it and the medic could not appeal or even try to make an argument as to why it should be ok, but had to take it himself.

And yes, the monthly actions are pretty cool.  You know exactly who has been behaving badly!  I'm always surprised at the number of random audits that they immediately revoke the licenses of people for.  They only do that when it is blatantly obvious that you made no attempt at recertification.  This is not a, well he for got a class, or came up 10 hours short type deal.  When they take it away with no plan on how to keep it, that's generally a "he said he took CEUs but didn't really do any of it" situation.  Shame.




NVRob said:


> You'd get reviewed and dinged here. You preformed an ALS technique.
> 
> "If you're suspicious enough to capture a 12-lead or put someone on the monitor you will attend that patient all the way to the hospital." -Our medical director.
> 
> I might get burned at the stake but I agree with him. Don't dish your partners calls after you started ALS interventions/assessments/techniques, it's not fair to your partner or your patient.



It depends.  Here capturing a 12-lead is a basic skill.  Technically interpretation is not allowed, so you send it off to medical control, and they tell you what to do about it.  I'm not saying, blanket statement, this is always ok, or it's always not, but I am saying that there are situations in which it could be ok, especially if there are other factors outside of patient care you have to be aware of.


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## Epi-do (Jan 1, 2012)

WuLabsWuTecH said:


> The medic might or might not write the chart himself.  There have been plenty of times on a busier run where both me and a medic have been in the back (running a three man crew) and I've written the entire thing only to have her read it and sign it at the hospital.  *There have also been times where the medic may have had to drive for whatever reason, and I've been in the back alone on a medic run and he ends up writing the entire thing at the hospital.
> *
> That may not be the applicable part of the SOP, I'll have to keep looking, but I know it is allowed because it was covered in my official training and not just something that everyone does and gets away with it.  We were told that it is allowed, but that if the lower level provider ever feels uncomfortable with the situation, then we could refuse it and the medic could not appeal or even try to make an argument as to why it should be ok, but had to take it himself.
> 
> ...



How on earth does that work?  If you aren't in the back with the patient, how can you know everything that was said and done?  Having a medic sign off on a lower providers report is one thing.  Having them write the report when they weren't the transporting provider seems like something entirely different to me.


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## Fish (Jan 1, 2012)

Bring it up to your medical director or clinical practices team, is this a field supervisor who was telling u this?


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## TheGodfather (Jan 1, 2012)

Fish said:


> Bring it up to your medical director or clinical practices team, is this a field supervisor who was telling u this?



It was a LT/Medic in charge of QA 
I addressed the issue with my MCP yesterday; Results:

1) any indication that patient may possibly be ALS should just be taken ALS. In the case of that specific patient, he stated that just doing a 12-lead to be proficient (if no real clinical s/s or risk factors present), I may perform an ECG and transmit prior to BLS transport.

2) for BLS patients (whom of which will most likely still require lab work) he stated as a form of courtesy to the ER, I may initiate an IV and lock/titrate to KVO rate. (state protocol allows this) --- He was unsure about the billing aspect of doing this.


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## tssemt2010 (Jan 1, 2012)

if you have to question it like this, then do the 12 lead, its not going to hurt anything


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## Tigger (Jan 1, 2012)

medic417 said:


> Really?  Again the *12 lead rules nothing out*.  If you suspect cardiac involvement Paramedic needs to keep patient.



If most every patient is getting a 12 because that is expectation of the system, isn't it not fair to the medic to have to take everyone in that has no signs or symptoms of cardiac issues? If you're doing a 12-lead because you suspect something cardiac the yes, the patient should be ALS, but if you're doing the 12-lead just for the sake of doing to cross it off a list I would think that grays the water a bit.


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## jjesusfreak01 (Jan 1, 2012)

Lets break this up, as there are two issues:

1. Should an EKG be done for this patient? 

Easy YES

2. Can this patient be handed down to BLS?

Depends. Most of the posters here are answering based on the protocols and policies of the systems in which they work; this doesn't really serve an educational purpose. The OP established that he did not require his EMT to do do anything outside of their scope, so that isn't an issue. If the OPs system has a rule about handing care down to EMTs, that should be followed. 

What I will say is this. The paramedic should have the discretion to do whatever diagnostic tests they deem necessary without being forced to run the call themselves when they believe it to be a BLS level call. If the paramedic does not anticipate the patient will need further ALS interventions following assessment, then there isn't a reason why the call cannot be run by an EMT-B. The EMT can monitor the patient's vital signs for deterioration. The reasoning is that if forbid something went terribly wrong with the patient in the back of the truck the basic should be able to handle the situation for the 20 seconds it takes the medic to pull over and hop in the back. 

As an aside, Wake County EMS puts an extra 5 minutes into their scene time limit for STEMI calls to allow an onsite EKG to be done, as destination triage is something that needs to be done before we leave the scene, ie, we are expected to complete a 12-lead onscene. Additionally, they are discussing the possibility of allowing EMTs to attend on calls where limited amounts of certain (generally safe) ALS medications have been given to the patients, indicating the medical director believes this to be a safe practice.


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## DrankTheKoolaid (Jan 1, 2012)

*re*

People seem to think the 12 lead is the issue in this discussion.  It really isnt.  The fact that an ALS procedure was performed ( IV start ) and then was handed to a BLS provider is the issue.  I would like to see anyone in Americas protocols stating specifically it is OK with your LEMSA / Medical Director that a BLS provider can assume care from their ALS partner after an ALS intervention was performed.  Standard care run of the mill calls not including MCI etc etc.


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## the_negro_puppy (Jan 1, 2012)

medic417 said:


> Really?  Again the *12 lead rules nothing out*.  If you suspect cardiac involvement Paramedic needs to keep patient.



Wrong. A 12 lead ECG can rule out a arrhythmia or significant ischaemia causing ECG changes at the very point of time it is performed. This is pretty important.


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## Tigger (Jan 1, 2012)

Corky said:


> People seem to think the 12 lead is the issue in this discussion.  It really isnt.  The fact that an ALS procedure was performed ( IV start ) and then was handed to a BLS provider is the issue.  I would like to see anyone in Americas protocols stating specifically it is OK with your LEMSA / Medical Director that a BLS provider can assume care from their ALS partner after an ALS intervention was performed.  Standard care run of the mill calls not including MCI etc etc.



Err say what? The OP has already addressed this, and his area has a protocol that allows for this. I don't see the hangup here, and I highly doubt the protocol was designed just "so basics can take transfers" exclusively. No one is required to wonder whether or not the protocol applies to them, it's written for everyone for a reason. 

And not that it matters, but many, many basics in Colorado can and do take patients that have an IV in that the medic started. Or the basic started the IV himself, and hung the fluid, and pushed the drugs (in a few specific scenarios). Not everywhere is like California.


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## medic417 (Jan 1, 2012)

the_negro_puppy said:


> Wrong. A 12 lead ECG can rule out a arrhythmia or significant ischaemia causing ECG changes at the very point of time it is performed. This is pretty important.



No it can rule in but it can not rule out. Lab is required to rule out.


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## DrParasite (Jan 1, 2012)

TheGodfather said:


> As an advanced care provider, is it wrong to perform diagnostic ECGs, interpret, transmit, and deem patient BLS?


in a nutshell, no.  if you do a 12 lead, find nothing abnormal, than you can deem the patient BLS.  

once you start the IV, it's automatically ALS.

however, if the patient is going to continue to receive cardiac monitoring during the trip, they should probably be ALS.


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## DrankTheKoolaid (Jan 1, 2012)

*re*



Tigger said:


> Err say what? The OP has already addressed this, and his area has a protocol that allows for this. I don't see the hangup here, and I highly doubt the protocol was designed just "so basics can take transfers" exclusively. No one is required to wonder whether or not the protocol applies to them, it's written for everyone for a reason.
> 
> And not that it matters, but many, many basics in Colorado can and do take patients that have an IV in that the medic started. Or the basic started the IV himself, and hung the fluid, and pushed the drugs (in a few specific scenarios). Not everywhere is like California.



Actually no he did not address it, he showed a generic protocol that was not specific and appears to be for BLS patients.  I have searched dam near every LEMSA in the nation over the last few days and have yet to find a wtritten protocol where a ALS care needing patient can be given to a BLS care provider especially a paramedic deemed it neccessary
 To start an IV.   If the patient is truely BLS why are they starting any IV at all.  Still waiting to see a protocol in writing the explicitly states this is deemed appropriate by a medical director.

I absolutely could be wrong...  But do please back up your knowledge with a verifiable referance


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## TheGodfather (Jan 1, 2012)

TheGodfather said:


> It was a LT/Medic in charge of QA
> I addressed the issue with my MCP yesterday; Results:
> 
> 1) any indication that patient may possibly be ALS should just be taken ALS. In the case of that specific patient, he stated that just doing a 12-lead to be proficient (if no real clinical s/s or risk factors present), I may perform an ECG and transmit prior to BLS transport.
> ...




not _specifically_ in writing, but it was verbalized face-to-face... i'm having trouble determining why this is so upsetting to you?


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## DrankTheKoolaid (Jan 1, 2012)

*re*

1. Its poor form, what exactly does this show to up and coming paramedics.  Thats its alright to be a glorfied IV starter and then turf your patient on a lower provider?

2. from a risk management standpoint, explain in a court while granny died because she was turfed onto BLS provider while there was a paramedic driving who had already deemed her worrisome enough to initiate a IV start.

Its thing like this that keep EMS at such a low standard,  we have so far to go especially with crap like this happeneing.   

That is why it is upsetting.


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## TheGodfather (Jan 1, 2012)

you are taking this to the extreme... in no case where there is any risk of death would i ever BLS a patient in to the hospital... we're talking about patients with local injuries, or common BLS problems (IE; my foot hurts, i stubbed my toe, i ran out of medication and i didnt feel like making a doctors appointment, im 25 and have a fever without other symptoms, etc. etc..) --this specific patient we were speaking of, may have been a little borderline, but that's as high of "risk" i'll go

i do this to be courteous... the nurses are busy enough then to have to spend time doing IV sticks that i can easily perform... not to mention i have faith that my partner can do his job (including monitoring IV locks) without any kind of issue...


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## Tigger (Jan 1, 2012)

Corky said:


> Actually no he did not address it, he showed a generic protocol that was not specific and appears to be for BLS patients.  I have searched dam near every LEMSA in the nation over the last few days and have yet to find a wtritten protocol where a ALS care needing patient can be given to a BLS care provider especially a paramedic deemed it neccessary
> To start an IV.   If the patient is truely BLS why are they starting any IV at all.  Still waiting to see a protocol in writing the explicitly states this is deemed appropriate by a medical director.
> 
> I absolutely could be wrong...  But do please back up your knowledge with a verifiable referance



Honestly though, who cares? In _his_ area it is allowable. 

For arguments, it is in my area too, not sure how you want me to prove it. I am trained to start and monitor IVs, and I am a basic. You can look on page 17 of this to find this to be an allowable skill for EMT-Basics with approval from their medical director. 

I firmly believe that ideally, every patient should be assessed by a paramedic. That doesn't mean they must always be treated by one though.


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## Fish (Jan 1, 2012)

medic417 said:


> Really?  Again the *12 lead rules nothing out*.  If you suspect cardiac involvement Paramedic needs to keep patient.



Nothing huh? I would beg tje differ.


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## usalsfyre (Jan 1, 2012)

If this came across my desk in a QA role, I'd nail you to the wall on it. Here's why.

1) First and foremost you failed to document your assessment findings in this patient. YOU assessed the patient first, ruled out etiology based on you knowledge base and performed an intervention that is out of a basic providers skill set. He shouldn't be documenting your assessment findings for you, and can't document his 12 lead interpretation. You've put him and yourself in a crappy position documentation wise.

2)You said it yourself, it's a borderline patient. This isn't letting a newer provider of the same level ride progressively harder calls, it's letting a lower level of care ride a patient that your concerned enough to do a full assessment on. Considering the majority of paramedics I've seen (spanning multiple agencies and states) have relatively poor assessment skills, I'm skeptical of your ability to "clear" a patient with an ambiguous problem.

3)Finally, the whole thing smacks of laziness. I can't determine intent, but your going to have a darn hard time convincing me there was anything educational about this for the Basic (and I'm going to ask what you taught him). You've got to accompany the patient to the ED anyway, just write the freaking chart. The way it's presented feels like "there's some cool stuff I can do, but once that's over, this call is beneath me". Weak dude.

I highly doubt your OMD intended for the "basics riding saline locks" to be used this way and what he intended is the final word. 

There are calls that are entirely appropriate for BLS providers to take, but if there's any question, part if being a paramedic is taking those borderline calls. It protects both partners and is part of being the leader on the truck. Anything else asking for trouble and a poor reflection in you as a provider.


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## TheGodfather (Jan 1, 2012)

by ways of verbalizing the parts of this call, it's hard to really depict what really was going on.. 

the EKG was done by me because any old person complaining of anything gets an EKG (usually); does that mean I have to ride in all old people? IMO, no.

the reason why i said it was "borderline" was based on hx alone... no symptoms, no complaints, just tried to cover my butt... 

and for a 3rd time...med control has directly told me that it is appropriate (and preferred) to have IV locks in place on any patient who will most likely require access/blood work once they hit the ED (even if BLS rides it in)

i am far from lazy... if anything, most providers would shut their partners in the back without even doing any assessment (just by basing the looks and complaint of the patient alone)... i have no problem writing charts, but i do have a problem taking away good BLS patient contacts from my equally enthused partner because i like to provide cautious, standardized patient care using all of the tools at my disposal....


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## usalsfyre (Jan 1, 2012)

TheGodfather said:


> the EKG was done by me because any old person complaining of anything gets an EKG (usually); does that mean I have to ride in all old people? IMO, no.


So your either not confident enough in your assessment skills to determine who it's actually appropriate to perform an EKG on or you were concerned there was an occult cardiac event and when the 12 lead came back with out a STEMI you thought "I'm good". Which is it? Because neither one is good. Your opinion doesn't mean a whole hell of a lot in this case, it's the opinion of your QA department and medical director that actually matters. And geriatrics have a lot of atypical presentations, so a negative EKG (in a paced patient at that) doesn't let you off the hook for advanced care.



TheGodfather said:


> the reason why i said it was "borderline" was based on hx alone... no symptoms, no complaints, just tried to cover my butt...


The patient had a vague, non-specific complaint with multiple comorbidities and as such you felt the need to "cover your butt", yet you turfed the call when a diagnostic test that's not sensitive for any number of serious conditions came back without one finding. See the problem here?



TheGodfather said:


> and for a 3rd time...med control has directly told me that it is appropriate (and preferred) to have IV locks in place on any patient who will most likely require access/blood work once they hit the ED (even if BLS rides it in)


My bad. I don't agree with it, but if the physician is comfortable with it, it's not my place to say.



TheGodfather said:


> i am far from lazy... if anything, most providers would shut their partners in the back without even doing any assessment (just by basing the looks and complaint of the patient alone)...


This is really about how it works in most places. It's very obviously BLS, or the medic needs to ride it. Number one because it's good patient care. Number two because if you don't get a good handle on things basics will be riding all sorts of things they shouldn't.



TheGodfather said:


> i have no problem writing charts, but i do have a problem taking away good BLS patient contacts from my equally enthused partner because i like to provide cautious, standardized patient care using all my tools at my disposal....


And what did your partner learn sitting in the back taking one more set of vitals that he hadn't already learned on scene? "Experience" is not all equal. 

"Throwing everything against the wall and seeing what sticks" may be fine for House M.D., but it's crappy real world medicine. The 12 lead was appropriate here, but nowhere near all elderly patients need 12 leads, just like not all patients need FSBGLs or IVs.

I'm not going to be able to convince you of why this was an issue, I simply ask that you take a step back and examine the REAL reason you turfed this call. I've got a BLS partner who is far, far more enthused about running calls than I am a lot of times. There's no way in hell I'd turf a call to her under the conditions described.


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## TheGodfather (Jan 1, 2012)

we can butt heads all day long about this... am i competent to determine who needs an ECG? yes. 

is the patient sick because she has a virus, or is she sick because of an underlying cardiac arrhythmia? Based on the fact that i dont have x-ray-ct-sonagraphic-super-cardiac-detecting eyes, I checked out her rhythm..

could there have been a underlying change in cardiac status? sure there COULD have. she COULD also be suffering from a number of other conditions that are undetectable by the prehospital care provider.... bottom line, transport time was 10 minutes... patient was complaint free... there was no obvious signs of any life-threatening condition... so i opted to let him ride... shame on me i guess!


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## usalsfyre (Jan 1, 2012)

TheGodfather said:


> we can butt heads all day long about this...


My point exactly. 

I get the feeling you've never had that patient who was "fine" crap out in a 10 minute transport because you weren't paying close enough attention. It's an eye opener when it happens. 

You'll find that as your assessment skills grow diagnostics often simply confirms what you know from a good history and physical exam.


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## TheGodfather (Jan 1, 2012)

no, i have, and to be quite honest, i can see from both ends of the perspective on this one... it's just one of those "you gotta be there" things... when it gets to the nitty gritty, if u were on scene with me, and you told me to ride it in, i would listen (given the simple fact that your experience trumps mine 10 fold)... my perspective was there was minimal risk, so i chose to let it go.. wrong? maybe. did she die in our care? no.


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## usalsfyre (Jan 1, 2012)

We are all armchair quarterbacking here, and it is hard to say one way or the other without laying eyes and hands on the patient. Some of it is preference and background on my part, when I was a (VERY) green basic I saw medics turf stuff they never should have with scary results.

We probably all make the wrong call (according to someone else) daily and get away with it. Agree to disagree?


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## fire87l2 (Jan 1, 2012)

*Concerning*

This concerns me as a medic. I feel that if an ALS assessment is performed, even if that assessment is negative, then the patient should be transported by a paramedic and not an EMT-B. Where I work, if I start an IV or a saline lock (even though EMT's can monitor those), I must maintain patient care. EMT-B's are only allowed to monitor IV's and saline locks after the patient has been evaluated by a physician and then are being transferred to another facility.

The fact that you allowed your partner to maintain patient care after an ALS assessment and intervention has been performed is downgrade of care and subsequently can be looked at as abandonment of patient care. This call should have never been billed as ALS if the medic was not in the patient compartment.


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## systemet (Jan 2, 2012)

My opinions:

* Failure to perform a 12-lead on this patient would be poor and potentially negligent patient care.  I think you were right to do the 12-lead.

* As many others have said, you can't use a 12-lead to rule out acute MI.  You need serial ECGs to rule out STEMI, and you need (likely serial) enzymes to rule out NSTEMI.

I agree that this patient is probably unlikely* to be an acute MI presentation [*unlikely as in improbable, not impossible].  Most likely, there's some sort of underlying infection, or medication intolerance / interaction.  But, as I think you probably understand, we can't rule out an AMI with the technology in most ambulances without sitting on scene for a few hours.

* I think your supervisor is worried about the potential liability if the patient ends up arresting / having some sort of cardiac event, or even an unrelated severe pathology, and there's documentation that the patient was transferred to BLS after being assessed with a 12-lead.

This seems like a bad reason to be worried.  A better reason to be worried would be because of the potential harm to the patient, not the potential legal liability.  

* Your system is set up to allow you to downgrade to BLS.  I'd imagine this criteria would be pretty well-defined.  If it's not.. then, I'd be riding a lot of BLS patients in ALS.  

There's a reality here, that if you've downgraded this patient without following the letter of your written protocol, you're going to get crucified if something happens.  It might not be fair, but ask yourself how many of your managers or medical directors or local area physicians would truely be there backing you up in a court of law, or in front of a professional competency committee?

If you've decided this patient doesn't require ongoing ALS care (and I'll assume that monitoring the IV is a BLS intervention), then that's a decision you have to be able to defend.  Is anyone going to support you?  Because it sounds like your immediate supervisor isn't.  

Maybe you need to sit back and have a think about whether you're happy with the decision you made, and whether you need to change your behaviour in the name of simple self-preservation.  You can get away with making risky decisions for a long time, but if you do it for long enough, the chance of a decision going the wrong way is going to increase.


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## WuLabsWuTecH (Jan 2, 2012)

Epi-do said:


> How on earth does that work?  If you aren't in the back with the patient, how can you know everything that was said and done?  Having a medic sign off on a lower providers report is one thing.  Having them write the report when they weren't the transporting provider seems like something entirely different to me.



I should qualify that a bit more.  He may write the whole thing but he consults with me while writing it.  In one particular instance, he did the assessment and 12 lead on scene, showed nothing (it was a call for an ill person), and decided to forgo the IV.  This was back when I was still not allowed to drive in inclement weather, and he saw no need to take another medic or engine out of service, so he drove.  Still an ALS run, he was still in-charge on the documentation.



Corky said:


> Actually no he did not address it, he showed a generic protocol that was not specific and appears to be for BLS patients.  I have searched dam near every LEMSA in the nation over the last few days and have yet to find a wtritten protocol where a ALS care needing patient can be given to a BLS care provider especially a paramedic deemed it neccessary
> To start an IV.   If the patient is truely BLS why are they starting any IV at all.  Still waiting to see a protocol in writing the explicitly states this is deemed appropriate by a medical director.
> 
> I absolutely could be wrong...  But do please back up your knowledge with a verifiable referance



Please not that the quote I gave was from my department.  I am not the OP, I am merely saying that in my area it is acceptable.  And while corky may disagree with my citation, it's the best I can find at the moment.  I know we can do this because it was specifically covered in our training.



TheGodfather said:


> you are taking this to the extreme... in no case where there is any risk of death would i ever BLS a patient in to the hospital... we're talking about patients with local injuries, or common BLS problems (IE; my foot hurts, i stubbed my toe, i ran out of medication and i didnt feel like making a doctors appointment, im 25 and have a fever without other symptoms, etc. etc..) --this specific patient we were speaking of, may have been a little borderline, but that's as high of "risk" i'll go
> 
> i do this to be courteous... the nurses are busy enough then to have to spend time doing IV sticks that i can easily perform... not to mention i have faith that my partner can do his job (including monitoring IV locks) without any kind of issue...



Right, these ALS runs are usually borderline ALS.  We're not talking about even borderline serious, the risk here to these patients is no more than a BLS run, hence why it's not that big of a deal to let a basic ride.



Tigger said:


> Honestly though, who cares? In _his_ area it is allowable.
> 
> For arguments, it is in my area too, not sure how you want me to prove it. I am trained to start and monitor IVs, and I am a basic. You can look on page 17 of this to find this to be an allowable skill for EMT-Basics with approval from their medical director.
> 
> I firmly believe that ideally, every patient should be assessed by a paramedic. That doesn't mean they must always be treated by one though.



In tiered systems, this is how it works, the medic gets there, does the assessment, and if there is truly nothing ALS about the run, the turf it to the BLS crew such that the ALS guys can remain in service.


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## firecoins (Jan 3, 2012)

TheGodfather said:


> this is a direct copy from my state protocols:
> 
> 
> 
> How would what I did be an unacceptable action based on how that is written? I deemed that the patient was not in any type of acute coronary syndrome... how would I then not be able to deem the patient BLS?



That is not a full protocol.  You deemed it necessary to do a 12 lead and start a line, its an ALS patent that warrents you taking it in.


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## DrParasite (Jan 3, 2012)

usalsfyre said:


> I get the feeling you've never had that patient who was "fine" crap out in a 10 minute transport because you weren't paying close enough attention. It's an eye opener when it happens.
> 
> You'll find that as your assessment skills grow diagnostics often simply confirms what you know from a good history and physical exam.


I've not a newbie by any stretch, and I have experienced patients that say they are fine one minute and we are doing CPR on next.  I've also had patients who looked like crap that ALS released, who we ended up bagging or doing CPR to halfway to the hospital (and often these releases were done over my objections, as the patient looked like crap).  

Doesn't mean every patient needs a monitor and IV during the trip to the hospital.  Also doesn't mean that the patient is having an atypical or silent MI, or some cardiac abnormality that isn't presenting normally.  

Plus is it really gonna hurt to throw some stickies on the patient and fire up the lifepak for a minute?  just to make sure everything looks good before your turf the patient to the EMT?



fire87l2 said:


> This concerns me as a medic. I feel that if an ALS assessment is performed, even if that assessment is negative, then the patient should be transported by a paramedic and not an EMT-B.


this concerns me as a provider.  are you nuts???? please tell me you are joking.  

This also concerns me as a potential patient of yours.  If I am on an ALS/BLS truck, I expect the ALS provider (who is more skilled, more educated and more experienced) to be the one conducting the assessment.  I want the best care and best assessment possible.  Then, once the ALS provider has determined that I don't need his help, than the BLS person can monitor my stable self to the hospital.  But I don't want an ALS bill just because the ALS provider had to take a look at me and determined that I didn't need his help.


fire87l2 said:


> The fact that you allowed your partner to maintain patient care after an ALS assessment and intervention has been performed is downgrade of care and subsequently can be looked at as abandonment of patient care. This call should have never been billed as ALS if the medic was not in the patient compartment.


absolutely wrong.  you didn't abandon your patient, you assessed your patient, determined your services were not needed, and left them in the capable hands of the BLS provider.  

The whole IV thing aside (which may constitute abandonment, depending on your local protocols and medical director's opinion), just doing an assessment doesn't automatically make it an ALS patient.

Ride in on the borderline jobs, but if the patient is stable, and you have ruled out everything using your assessment tools, let the EMT babysit for the ride in.  And if something does happen enroute, pull over, and the EMT will drive while the medic deals with the emergency.


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## flanaganj (Jan 3, 2012)

I don't know about you guys, but a 12 lead is routine ALS. If they get an assessment that includes the monitor they get a 12 lead. Period. Doesn't cost money and ill be damned if I'm called anything less then thorough. 

A 12 lead is always justified if you, as a medic, want to do one. What NEEDS to be justified is when you DONT do a 12 lead on am als assessment.

Sent from my Nexus S 4G using Tapatalk


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## tacitblue (Jan 4, 2012)

flanaganj said:


> I don't know about you guys, but a 12 lead is routine ALS. If they get an assessment that includes the monitor they get a 12 lead. Period. Doesn't cost money and ill be damned if I'm called anything less then thorough.
> 
> A 12 lead is always justified if you, as a medic, want to do one. What NEEDS to be justified is when you DONT do a 12 lead on am als assessment.
> 
> Sent from my Nexus S 4G using Tapatalk


I don't know that a 12 lead is justified every time a patient is placed on a monitor. If you preform 12 lead electrocardiograms on every ALS patient you take without a pretest suspicion of something, you may very well wind up with data that you don't know how to use. You may also increase your liability on some runs.


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## DrParasite (Jan 4, 2012)

tacitblue said:


> I don't know that a 12 lead is justified every time a patient is placed on a monitor. If you preform, my  12 lead electrocardiograms on every ALS patient you take without a pretest suspicion of something, you may very well wind up with data that you don't know how to use. You may also increase your liability on some runs.


huh?  please explain how a paramedic, who is an expert in 12 leads, and is trained on what to look for, and what do if it looks abnormal, is created increased liability if he or she 12 leads everyone?

if anything, the argument could be made (not that i would make it, only to argue the other side) that failing to to a 12 lead that could show a potential cardiac episode that is presenting abnormally, increases your liability because you are willingly failing to use a diagnostic tool that is readily available to you that would have detected the problem.

just saying in response to your post, nothing else.


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## triemal04 (Jan 4, 2012)

Way to start the new year off with a bang.  I had a nice, long responce all thought out and about half written, with each innacurracy, falsehood and just plain silly statement pointed out and corrected when I realized that a) that would take a very long time to write, and b) it would be pointless.

This is just another prime example of how lacking medical education is in the US for ALL prehospital providers, and how even a "paramedic" here can prove that they don't know squat.

TheGodfather-
I'll go out on a limb and say that you did a complete assessment of this patient to the best of your abilities and just didn't post every minute detail.  If that is the case, you did nothing medically wrong.  It may have been against your companies policy, and that is something you'll have to live and deal with (or move on or try and change), but from a medical standpoint...you did fine.

Everyone else-
Please explain why this patient needed a paramedic in constant, direct attendance.  And bear in mind when answering that the only real answer must be based on medicine; no "because my protocols say so" no "because it's "the law,"" no "because it's policy," no "because all patients need a paramedic with them," no "paramedics aren't smart enough to make that decision," nothing like that.  I would like to hear an honest medical reason why this patient, as presented, and going off the assumption that there was nothing else untoward found in the physical or history, could not be transported by a lower level of care.

You should also bear in mind what will happen to this patient when they arrive at the ER.  At some point in the first 30 minutes or so they will get their BP checked, labs drawn, probably an IV started, and an EKG (12lead) done.  The doctor (or PA or NP if they go to a fastrack type unit) will come in and do a cursory exam.  And that's all.  Nothing acute or hurried until their test results are in.

So please, tell me:  what was the medical reason that this patient needed a paramedic in constant attendance, and why has everyone flipped out?


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## tacitblue (Jan 4, 2012)

DrParasite said:


> huh?  please explain how a paramedic, who is an expert in 12 leads, and is trained on what to look for, and what do if it looks abnormal, is created increased liability if he or she 12 leads everyone?
> 
> if anything, the argument could be made (not that i would make it, only to argue the other side) that failing to to a 12 lead that could show a potential cardiac episode that is presenting abnormally, increases your liability because you are willingly failing to use a diagnostic tool that is readily available to you that would have detected the problem.
> 
> just saying in response to your post, nothing else.



Whenever you preform a diagnostic test, you should have a pretest suspicion and the test you are performing is ether to confirm your hunch or help rule it out. You will also need to take into account the specific test's sensitivity and specificity for identifying the suspected pathology.

Would you also fault the emergency physician for not ordering an abdominal CT scan on a post roll over MVA trauma patient with multiple benign abdominal exams? Even though that test is readily available to him and he is an "expert" in it's interpretation? Do you know how sensitive a CT o the abdomen is in locating a surgical problem even if one exists? It's not as high as you might think.

I I have a patiet with a headache which is severe, and I start a line and give morphine and zofran, it's an ALS call correct? Well, by the logic of the poster I was replying to in my first post, this patient would get a 12 lead. What if the 12 lead showed a left bundle branch block and this patient denies ever having one before? Are you going to activate the cath lab? No. Then why did you do the 12 lead?


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## DrankTheKoolaid (Jan 4, 2012)

triemal04 said:


> Way to start the new year off with a bang.  I had a nice, long responce all thought out and about half written, with each innacurracy, falsehood and just plain silly statement pointed out and corrected when I realized that a) that would take a very long time to write, and b) it would be pointless.
> 
> This is just another prime example of how lacking medical education is in the US for ALL prehospital providers, and how even a "paramedic" here can prove that they don't know squat.
> 
> ...



And what if this patient has another syncopal episode.  Remember this wasn't a fall, this was a syncopal episode causing the fall.  Under a paramedics care while being monitored if the patient had another episode of the arrhythmia (if thats what it was) it would be captured and identified and treated accordingly.  

Simply put, a syncopal episode his cardiac in origin until proven otherwise by a physician.  And there is no excuse not to have this patient cardiac monitor for the trip into the ED.

Being a paramedic means being a strong patient advocate.  And would a true patient advocate allow an elderly syncopal episode patient to be fast tracked or triaged out of the ambulance into the waiting room the way a lot of patients are when BLS'ed into the ED, No.  Any patient advocate is going to assure this patient is cared for and monitored while enroute to the highest level needed / warranted and also to the best of his ability at least formulate a coherent verbal report to the ED staff to make sure they are not brushed off into a corner and left to dwindle. If a BLS provider unsure of how or simply doesn't know enough to paint a good enough picture or a don't give a damn paramedic can not convey the need for immediate evaluation in a busy ED system that is exactly what is going to happen.


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## Shishkabob (Jan 4, 2012)

...Even the most critical of ICU patients don't have a healthcare provider with direct eye contact them every second they are there.



Just sayin'.


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## systemet (Jan 4, 2012)

tacitblue said:


> Whenever you preform a diagnostic test, you should have a pretest suspicion and the test you are performing is ether to confirm your hunch or help rule it out. You will also need to take into account the specific test's sensitivity and specificity for identifying the suspected pathology.



I agree with this, but I think you would accept that the OP has an indication for the 12-lead here, right?  He has a weak old lady.  This weakness could result from an arrhythmia, or could be an anginal equivalent, and might be symptomatic of cardiac ischemia.  There's also a remote possibility that there may be some sort of electrolyte abnormality that might be detectable (even if the ECG is pretty insensitive here).




> Would you also fault the emergency physician for not ordering an abdominal CT scan on a post roll over MVA trauma patient with multiple benign abdominal exams?  Even though that test is readily available to him and he is an "expert" in it's interpretation? Do you know how sensitive a CT o the abdomen is in locating a surgical problem even if one exists? It's not as high as you might think.



I actually have no idea about the sensitivity.  I'm not trying to be argumentative, but if you have a decent reference handy, I'd love to take a look.  I can also pubmed this myself, so don't kill yourself looking for it.



> I I have a patiet with a headache which is severe, and I start a line and give morphine and zofran, it's an ALS call correct? Well, by the logic of the poster I was replying to in my first post, this patient would get a 12 lead. What if the 12 lead showed a left bundle branch block and this patient denies ever having one before? Are you going to activate the cath lab? No. Then why did you do the 12 lead?



But what if the LBBB meets Sgarbossa criteria?  Or there's a clear STEMI?  In these situations, we might have to accept that the patient has both a severe headache and a cardiac event occuring simultaneously, that may be related or coincidental.

I remember reading some time ago (and I don't have a reference at hand), that there's a fair incidence of MI in patients experiencing a CVA.  I think a 90 year old having a severe headache will probably be getting a 12-lead in the ER.  Why not in the ambulance?  [I accept that a 19 year old female with no CV risk factors, might not].

There also (albeit fairly insensitive) ECG changes that can occur with increased ICP.  While it's not going to mean a whole lot if they're absent, surely if we see them, it might be interesting in the differential diagnosis of the headache.


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## DrankTheKoolaid (Jan 4, 2012)

*re*

disregard my last post, mixed up threads


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## epipusher (Jan 4, 2012)

You could argue that the majority of our patients do not require a paramedic in direct patient contact. It does not take away, imo, why this run, as with others, are ALS runs.


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## triemal04 (Jan 4, 2012)

epipusher said:


> You could argue that the majority of our patients do not require a paramedic in direct patient contact. *It does not take away, imo, why this run, as with others, are ALS runs*.


Ok...but why?  I'm being serious here; if EMS is ever going to be thought of as a serious medical profession and paramedics as true, educated medical providers, then this needs to be answered.  Using the criteria I laid out above.  Why, in your medical opinion, did this patient need a paramedic, and not an EMT?

The patient, as presented, needed to be seen by either a doctor or midlevel provider (PA/NP) who could order and interpret the needed tests, and then prescribe any needed medications and/or refer the patient to the appropriate level of follow-up care.  That's all.  

And...you're right, many of the patients that are taken in by paramedics DO NOT need that level of care.  There is a group of patients when a prehospital intervention will make a difference in the patient's overall outcome.  There's another group that a prehospital intervention will make a difference in the patient's immediate level of comfort.  And there's another group that could benefit from a good, competant paramedic taking them in as their report to the recieving facility could speed up the care given.  But, for the vast majority, it really doesn't make a difference.*


Corky said:


> disregard my last post, mixed up threads


Thought I'd missed something for a second.  But, since you did respond...what do you think?  Why did this patient need a paramedic?

*Obviously this will vary by system and the type of calls that paramedics are dispatched on; one group may see many more patient's that truly need care than another.


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## triemal04 (Jan 4, 2012)

Linuss said:


> ...Even the most critical of ICU patients don't have a healthcare provider with direct eye contact them every second they are there.
> 
> 
> 
> Just sayin'.


Well...a good ICU that really follows a 1:1 RN to patient ratio will come pretty damn close.  And the more unstable that patient is the more time a RN  will be in the room or very close by.


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## DrParasite (Jan 5, 2012)

systemet said:


> I remember reading some time ago (and I don't have a reference at hand), that there's a fair incidence of MI in patients experiencing a CVA.  I think a 90 year old having a severe headache will probably be getting a 12-lead in the ER.  Why not in the ambulance?  [I accept that a 19 year old female with no CV risk factors, might not].


IIRC, it was 20% of CVA patients are also having a cardiac related problem or MI.  





Corky said:


> Being a paramedic means being a strong patient advocate.  And would a true patient advocate allow an elderly syncopal episode patient to be fast tracked or triaged out of the ambulance into the waiting room the way a lot of patients are when BLS'ed into the ED, No.


and an EMT can't be a strong patient advocate?  please explain why not?  





Corky said:


> Any patient advocate is going to assure this patient is cared for and monitored while enroute to the highest level needed / warranted and also to the best of his ability at least formulate a coherent verbal report to the ED staff to make sure they are not brushed off into a corner and left to dwindle.


exactly, the highest level of care that is warranted based on the situation.  Sometimes that is an EMT.  and maybe not in your state, but there are quite a few EMTs who can formulate a coherent verbal report to the ED staff to make sure they are not brushed off into a corner and left to dwindle.  I know I've done it, and seen others give great reports to ER staff as well.   





Corky said:


> If a BLS provider unsure of how or simply doesn't know enough to paint a good enough picture or a don't give a damn paramedic can not convey the need for immediate evaluation in a busy ED system that is exactly what is going to happen.


and what if the BLS provider does know what he is doing and can paint the picture? does that mean there is no need for the medic?  

I've been blown off by the nurse on a serious patient.  She wanted to have me put the patient in the fast track section of the ER.  A quick chat with one of the ER attendings was all I needed to do to move the patient back to the  emergency section of the ER.  So you don't need to be a medic in order to be a patient advocate.





tacitblue said:


> Whenever you preform a diagnostic test, you should have a pretest suspicion and the test you are performing is ether to confirm your hunch or help rule it out. You will also need to take into account the specific test's sensitivity and specificity for identifying the suspected pathology.


do you test every patient's blood sugar?  as part of their vital signs?  if so, why not do 12 lead as part of your vital signs to look for any abnormality?


tacitblue said:


> Would you also fault the emergency physician for not ordering an abdominal CT scan on a post roll over MVA trauma patient with multiple benign abdominal exams? Even though that test is readily available to him and he is an "expert" in it's interpretation? Do you know how sensitive a CT o the abdomen is in locating a surgical problem even if one exists? It's not as high as you might think.


if the patient was bleeding into his abdomen and subsequently died, and that injury could have been fixed if he had done the CT?  yes, I think I might find a little fault in that.





tacitblue said:


> I I have a patiet with a headache which is severe, and I start a line and give morphine and zofran, it's an ALS call correct? Well, by the logic of the poster I was replying to in my first post, this patient would get a 12 lead. What if the 12 lead showed a left bundle branch block and this patient denies ever having one before? Are you going to activate the cath lab? No. Then why did you do the 12 lead?


will the CATH lab be able to fix the left bundle branch block?  What if it shows a STEMI?  gonna activate the CATH lab?  what about new onset of AFib?  would that warrant treatment?  how about a pulse ox of 70?  think that might warrant you doing some type of corrective action, even if it's asymptomatic or abnormal symptoms?


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## Handsome Robb (Jan 5, 2012)

tacitblue said:


> I I have a patiet with a headache which is severe, and I start a line and give morphine and zofran, it's an ALS call correct? Well, by the logic of the poster I was replying to in my first post, this patient would get a 12 lead. What if the 12 lead showed a left bundle branch block and this patient denies ever having one before? Are you going to activate the cath lab? No. Then why did you do the 12 lead?



Why wouldn't you activate the cath lab?

new onset LBBB needs diagnostic and possibly interventional catheterization. Where did the LBBB come from? Is it ischemic in origin and the LBBB is hiding the STEMI? 

If you aren't going to cath them they at minimum need to go to the angio suite.


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## tacitblue (Jan 5, 2012)

NVRob said:


> Why wouldn't you activate the cath lab?
> 
> new onset LBBB needs diagnostic and possibly interventional catheterization. Where did the LBBB come from? Is it ischemic in origin and the LBBB is hiding the STEMI?
> 
> If you aren't going to cath them they at minimum need to go to the angio suite.



I have a bundle branch block, I'm in my mid 20s. I wouldnt call in a cath activation for a patiet with a headache and an incidental LBBB on a 12 lead that I my self wouldn't have preformed. A lot of people walk around with them, and unless I'm working up a patient and ACS is in the differential, an LBBB is probably going to be treated as an incidental finding.


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## triemal04 (Jan 5, 2012)

NVRob said:


> Why wouldn't you activate the cath lab?
> 
> new onset LBBB needs diagnostic and possibly interventional catheterization. Where did the LBBB come from? Is it ischemic in origin and the LBBB is hiding the STEMI?
> 
> If you aren't going to cath them they at minimum need to go to the angio suite.


Really?  Really?  Is that what you think you've learned in school?  That because somebody does not know that they have a LBBB, something that they may have had for years, been told about and forgot, or possibly never been told about in more than a passing way you should immedietly call for the cath lab to be opened when they say "no, I don't think I have that problem"?

Do you really think that the patient with a LBBB of unknown duration and no other cardiac symptoms will be placed in an "angio suite?"  

Do you really know what actually goes on in a hospital after you drop off a "critical" cardiac/CVA/trauma/whatever patient?

:censored::censored::censored::censored: me.  http://www.medscape.com/medline/abstract/19857407  That's an abstract but all I can post that you'll have access to.  http://www.medscape.com/viewarticle/717550  There's a nice interpretation of the same study for you.  The final sentence would be the most pertinent.

Part of learning and being competent is keeping up with developing trends.  Granted, this is only one study but it is much better to follow than simply saying a "new" LBBB=trip to the cath lab without knowing what you are talking about.

Mods feel free to delete if this is considered "not nice."


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## Handsome Robb (Jan 5, 2012)

tacitblue said:


> I have a bundle branch block, I'm in my mid 20s. I wouldnt call in a cath activation for a patiet with a headache and an incidental LBBB on a 12 lead that I my self wouldn't have preformed. A lot of people walk around with them, and unless I'm working up a patient and ACS is in the differential, an LBBB is probably going to be treated as an incidental finding.



I'll agree to disagree. At the least the receiving ER is going to hear about this new onset BBB so the doc can decide what to do with it. 

I agree, people do walk around with them all the time, but what's the etiology behind this one. I'm not sure I would call it incidental with symptoms presenting, even if they aren't textbook cardiac. 

My thought process just for :censored::censored::censored::censored:s and giggles. Severe headache + new onset LBBB could very well be a CVA and AMI from something throwing multiple clots...but that's a pretty big zebra depending on the age, health and history of the patient as well as completely defies Occam's razor.

triemal the thread started with a 90 year old patient, I'm willing to bet they would have noticed a BBB by now but hey I'm just a young dumb medic student so feel free to disregard anything I have to say about it. 

I'll bow to your superiority now.


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## triemal04 (Jan 5, 2012)

NVRob said:


> triemal the thread started with a 90 year old patient, I'm willing to bet they would have noticed a BBB by now but hey I'm just a young dumb medic student so feel free to disregard anything I have to say about it.
> 
> I'll bow to your superiority now.


And the original post had nothing to do with the post that referenced a LBBB.  For kicks, let's say that it did.  So, by your criteria you would activate the cath lab for this patient?  Why?  For what reason?

Do you really think that it is that out of the ordinary for people...MANY people to walk around with a bundle branch block and have no clue that it's there, even if they were told about it?  It's like afib that way.  There is a reason that a previous EKG is needed to make that determination, and even then, unless it was a very, very recent one, or there are extenuating circumstances (like elevated cardiac enzymes, symptoms of ACS, a LBBB with concordance, etc etc) it still isn't a sure thing.  New is a relative term.

I'm not superior to anyone.  Inferior to most usually.  But you are close to finishing school.  Now is when you get to decide what type of paramedic you will be.  It can either be the type that only listens to other pseudo-paramedics, or the kind that follows along, as best they can, with medicine.  You can think about what is happening, and make your decisions based on what is appropriate, or what "that really smart paramedic told me to do."


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## Handsome Robb (Jan 5, 2012)

triemal04 said:


> And the original post had nothing to do with the post that referenced a LBBB.  For kicks, let's say that it did.  So, by your criteria you would activate the cath lab for this patient?  Why?  For what reason?
> 
> Do you really think that it is that out of the ordinary for people...MANY people to walk around with a bundle branch block and have no clue that it's there, even if they were told about it?  It's like afib that way.  There is a reason that a previous EKG is needed to make that determination, and even then, unless it was a very, very recent one, or there are extenuating circumstances (like elevated cardiac enzymes, symptoms of ACS, a LBBB with concordance, etc etc) it still isn't a sure thing.  New is a relative term.
> 
> I'm not superior to anyone.  Inferior to most usually.  But you are close to finishing school.  Now is when you get to decide what type of paramedic you will be.  It can either be the type that only listens to other pseudo-paramedics, or the kind that follows along, as best they can, with medicine.  You can think about what is happening, and make your decisions based on what is appropriate, or what "that really smart paramedic told me to do."



Fair enough. My biggest problem is looking at the big picture and I will admit that.


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## triemal04 (Jan 5, 2012)

NVRob said:


> Fair enough. My biggest problem is looking at the big picture and I will admit that.


More often than not that can be the problem that get's a lot of people in trouble.  And why there is such a problem in the US.

If I came across as harsh I do apologize, this is just one of those days when the posts here have lowered my threshold for aggravation.  And the beer doesn't help either...:blush:

I am serious though when I say that this is the time when you get to decide what type of paramedic you will be.  Don't stop learning and only listen to those around you, and don't decide to not use resources and information that is available because other people at your level don't.  But, at the same time, while you should be aware of zebra's, don't get caught up in them and ignore what is actually happening right in front of you.  

You've hopefully learned quite a bit going through school, and hopefully will continue to seek out better educational opportunities, but, moreso initially than later on, there will be a problem in sorting out all that info and applying it to the situation at hand.  It is easy to get bogged down and start chasing imaginary problems.  Try not to do that.  If looking at the big picture really is a problem for you (and kudos for being able to recognize that) then don't go to work somewhere that doesn't have a strong FTO program.  As with deciding how much or little you want to continue to learn, don't set yourself up for failure by going somewhere where you won't have any direction.





And don't listen to drunk people on the internet when it's 11pm.  :beerchug:


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## tacitblue (Jan 5, 2012)

DrParasite said:


> IIRC, it was 20% of CVA patients are also having a cardiac related problem or MI.  and an EMT can't be a strong patient advocate?  please explain why not?  exactly, the highest level of care that is warranted based on the situation.  Sometimes that is an EMT.  and maybe not in your state, but there are quite a few EMTs who can formulate a coherent verbal report to the ED staff to make sure they are not brushed off into a corner and left to dwindle.  I know I've done it, and seen others give great reports to ER staff as well.   and what if the BLS provider does know what he is doing and can paint the picture? does that mean there is no need for the medic?
> 
> I've been blown off by the nurse on a serious patient.  She wanted to have me put the patient in the fast track section of the ER.  A quick chat with one of the ER attendings was all I needed to do to move the patient back to the  emergency section of the ER.  So you don't need to be a medic in order to be a patient advocate.do you test every patient's blood sugar?  as part of their vital signs?  if so, why not do 12 lead as part of your vital signs to look for any abnormality?
> if the patient was bleeding into his abdomen and subsequently died, and that injury could have been fixed if he had done the CT?  yes, I think I might find a little fault in that.will the CATH lab be able to fix the left bundle branch block?  What if it shows a STEMI?  gonna activate the CATH lab?  what about new onset of AFib?  would that warrant treatment?  how about a pulse ox of 70?  think that might warrant you doing some type of corrective action, even if it's asymptomatic or abnormal symptoms?


Even when one does everything right, things can be missed. Reason I mention the CT is that  there is evidence that serial abdominal exams are more sensitive for surgical bellies than a CT scan. Medical providers have to weigh risk vs benefit and critically analyze each test they want to preform to find utility. A CT scan is the equivalent of hundreds of x rays, that's a lot of radiation that could be avoided when there is a better an cheaper option. However, every once in a while one may slip through the cracks. 

I'm not trying to be a douche, but do you understand the concept of sensitivity and specificity? It's good to know. And, If I am performing a 12 lead as part of my "vital signs assessment" on every patient, I am doing something very wrong. 
These take time and will add Very little of value in the workup of many o my patients. By your logic, why not throw every patien on side stream capnograpghy just to check out how they are ventilating... Many many folks are seen at the ED for various complaints and certain tests that you think might be preformed are not, because a competent emergency physician was able to apply her knowledge of the utility of these various tests to the patient's presentation and decide they were not useful and would not add value to the workup. In the process she saves the patient a significant amount of money and the dangers that over testing can produce.

You can look in almost any area of medicine and see controversy over various tests. Look at Prostate Specific Antigen or breast cancer screening. Sometimes getting information from a test can really only add confusion and uncertainty to the clinical picture.


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## Handsome Robb (Jan 5, 2012)

triemal04 said:


> More often than not that can be the problem that get's a lot of people in trouble.  And why there is such a problem in the US.
> 
> If I came across as harsh I do apologize, this is just one of those days when the posts here have lowered my threshold for aggravation.  And the beer doesn't help either...:blush:
> 
> ...



No worries dude, no offense taken. I understand the grumpiness I had an episode of it yesterday as well. 

The agency I work at as an Intermediate now and hope to move up to a medic spot at the end of school seems to have a pretty solid FTO period. 6 weeks with an FTO then 6 months as a second seat medic before you are cleared to work with an Intermediate partner. Not the most progressive protocols but not mother-may-I by any means. 

When I can look at something it is much easier for me to see the big picture rather than reading something but I still definitely need to do a lot of work on it either way. The cool thing about now is all the partners I have worked with so far have always asked me what I'm thinking "from a medic point of view" either on scene or after the fact. It has helped quite a bit. 

I don't want to be that guy that finishes school then just does the minimal CEUs to keep my cert up. It is just very overwhelming with school right now and all the conflicting information when it comes to textbook vs. real life. 

Drink a brew for me! :beerchug:

Sorry to derail the thread, back to the scheduled programming


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## tacitblue (Jan 5, 2012)

tacitblue said:


> Even when one does everything right, things can be missed. Reason I mention the CT is that  there is evidence that serial abdominal exams are more sensitive for surgical bellies than a CT scan. Medical providers have to weigh risk vs benefit and critically analyze each test they want to preform to find utility. A CT scan is the equivalent of hundreds of x rays, that's a lot of radiation that could be avoided when there is a better an cheaper option. However, every once in a while one may slip through the cracks.
> 
> I'm not trying to be a douche, but do you understand the concept of sensitivity and specificity? It's good to know. And, If I am performing a 12 lead as part of my "vital signs assessment" on every patient, I am doing something very wrong.
> These take time and will add Very little of value in the workup of many o my patients. By your logic, why not throw every patien on side stream capnograpghy just to check out how they are ventilating... Many many folks are seen at the ED for various complaints and certain tests that you think might be preformed are not, because a competent emergency physician was able to apply her knowledge of the utility of these various tests to the patient's presentation and decide they were not useful and would not add value to the workup. In the process she saves the patient a significant amount of money and the dangers that over testing can produce.
> ...


 and just a quick follow up for DrParasite; the cath lab isn't going to "fix" a left bundle block, but in patients where ACS is likely based on their history and physical- finding a new or presumably new LBBB on the electrocardiogram is considered a STEMI and treated as such. The reason I brought it up in my original post was to demonstrate why a pretest suspicion is needed to guide interpretation; some people have LBBBs and teasing out folks who need to go to the cath lab now is based on why you even did the 12 lead in the first place. And see, that is it right there. Hang out here for a minute with me and really think about that.

Throwing everything at a patient to see what sticks may leave you going down a path that has nothing to do with what is really going on.


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## DrParasite (Jan 5, 2012)

tacitblue said:


> Even when one does everything right, things can be missed. Reason I mention the CT is that  there is evidence that serial abdominal exams are more sensitive for surgical bellies than a CT scan. Medical providers have to weigh risk vs benefit and critically analyze each test they want to preform to find utility. A CT scan is the equivalent of hundreds of x rays, that's a lot of radiation that could be avoided when there is a better an cheaper option. However, every once in a while one may slip through the cracks.


you know, you might be right.  A lot of radiation vs the slim chance of finding anything.  I agree.  unless your dead family member is the one who slipped through the cracks.  and mom/dad/son/daughter would still be alive if they had done the CT scan, had been that one who slippled through the cracks, and fixed the problem, would you still be against CT scan of the abdomen following the serious MVA?


tacitblue said:


> I'm not trying to be a douche, but do you understand the concept of sensitivity and specificity? It's good to know. And, If I am performing a 12 lead as part of my "vital signs assessment" on every patient, I am doing something very wrong.
> These take time and will add Very little of value in the workup of many o my patients.


time?  what, maybe 5 minutes to do a 12 lead?  apply 12 stickies, tell the patient to hold still, analyze, save, print, look at results?  99% of the time it looks normal, 1% of the time it shows something significant, and you are aware of it before it becomes critical?   Ok, so the CT scan is a lot of radiation, that's bad, I agree, what's the downside to a 12 lead?  you need to buy another package of stickies?  a little electricity through the patient?





tacitblue said:


> By your logic, why not throw every patien on side stream capnograpghy just to check out how they are ventilating... Many many folks are seen at the ED for various complaints and certain tests that you think might be preformed are not, because a competent emergency physician was able to apply her knowledge of the utility of these various tests to the patient's presentation and decide they were not useful and would not add value to the workup. In the process she saves the patient a significant amount of money and the dangers that over testing can produce.
> 
> You can look in almost any area of medicine and see controversy over various tests. Look at Prostate Specific Antigen or breast cancer screening. Sometimes getting information from a test can really only add confusion and uncertainty to the clinical picture.


You know, we can go back and forth on this, but the reality is, in the ER, if you are sick, and old, you get a 12 lead.  if you come in by ambulance with toe pain, you get a 12 lead.  if you come in with abd pain, you get a 12 lead.  if you come in with an ear ache, you get a 12 lead.  doesn't cost much, isn't invasive, doesn't take much time, and it's part of your medical chart.  most of the time, it shows nothing abnormal.  and if something abnormal is found, well, now you know, it can be properly investigated to ensure it's not life threatening.

most of the time, yes, it's a waste of time and stickies, I won't disagree.  but it's still done, and if people who make more money and have more education in medicine do it as a standard practice, maybe you can admit they might know a little bit more than you?

If not, lets agree to disagree.  Time to move on to bigger and better disagreements.


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## EMSLaw (Jan 5, 2012)

Corky said:


> Emslaw whats your take as a practicing lawyer on this.  Especially if something went wrong and the BLS hadnt noticed it or patient wasnt still on the monitor.



It gets complicated.  Really, lawsuits against EMS providers are fairly rare, as far as I can tell, at least for medical related things (as opposed to wrecking out your rig on the way to the call).  That is, in reported opinions.  It's always hard to tell what goes on that doesn't result in an opinion or is settled.  There are ways to find out, but I will admit I haven't done the research.  It would make an interesting presentation someday. 

Getting back on point, the question is going to be whether a reasonable paramedic under the circumstances would have done the same thing, one.  And two, whether the outcome would have been any different had things been done in the way a reasonable paramedic would have done them.

Say your released patient codes.  Presumably, the EMT realizes this and starts CPR, while the medic pulls over and goes to work.  The patient dies.  The question would then be whether if there had been a medic in the back, anything would have happened differently than it did.  It's entirely possible the answer is no.  Patients die even in world-class research hospitals every day, and there's nothing that can be done to prevent it.  If the answer is yes, though, then there would be trouble.  

So, my take is that it would be a very situation-dependent issue.  Starting a line on the patient is an ALS treatment, though, as opposed to a mere evaluation, so that might enter into it.  If your medical control signs off on you releasing to BLS, then it will be more on him, as the ultimate medical authority.

The best I can do is equivocate.  If there's no indication from any diagnostic tools in the field that the patient requires a paramedic, then based on the information available, would a reasonably prudent paramedic still have ridden the call in?  If yes, then would the outcome have been any different?  A lot of it is going to depend on your local protocols, both the written ones and the way things operate on a day-to-day basis.   

For example, NJ is an interesting place when it comes to EMS.  Not only because we have a tiered system, but also because we have a dearth of paramedics (something like 1500 active medics in the entire state).  In suburbia or the more rural parts of the state, ALS might not always be available.  As a BLS provider, I'm expected to have a good understanding of what paramedics can do.  The idea that every patient needs a paramedic is foreign to me - and would get me frequent posterior-chewings from the local medics (who expect to be cancelled when my 'chest pain with difficulty breathing' job turns out to be a hyperventilating 16 year old, or something like that).  Some EMTs are more 'paramedic dependent' than others, and Paramedics can release to BLS after evaluation.  However, the last step in that process is asking the BLS crew if they are comfortable treating the patient.  If the answer is 'no', then the paramedic should ride the call in anyway. Is the whole process reasonable?  I don't know if it's ever been tested.  

Sorry I can't be more helpful.


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## epipusher (Jan 7, 2012)

Previous cardiac arrest patient now has ROSC. Pt is intubated with bvm assistance(bls skill). IV slowed to tko rate(bls skill). No more drugs needed to be given(no amio or lido drip). Perfect sinus at 80, 12-lead unremarkable. Pt is now bls, correct?? Direct paramedic contact is no longer needed per a previous post or two.


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## Veneficus (Jan 7, 2012)

*late to the party,didn't read the whole thread*

But I agree with the whole first page mostly.

This patient needed a 12 lead.

This patient should not have been turfed to BLS.

if I could?

Elderly patients only usually present with symptoms of general illness, even when they are extremely sick. Including with conditions that are not consistent with the symptoms.

12 lead for acute MI.

Did you interpret the 12 lead for all of the conditions it can pick up or just ST elevation?

If just the later, then you made an error in turfing to BLS.

IV therapy...

If you started an IV because "just in case, to help out the hospital, or any other reason than for treatment, you made a medical error of performing an unindicated procedure. (This is especially true if the facility has a policy of removing field IVs and placing their own)

Getting paid for what you do.

I can also see why your service is upset they equipped and trained and ALS provider at considerable expense to be paid for less. Much less.

If you go to a doctor with a complain and it turns out to be minor, do you think you will be billed less than the basic rate the doctor charges for being a doctor because you did not need an advanced treatment?


I do not agree with your supervisor as to why but it looks to me like you made a mistake. Something all of us do from time to time.

Not the end of the world, use it as a learning experience and move on.


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## triemal04 (Jan 7, 2012)

epipusher said:


> Previous cardiac arrest patient now has ROSC. Pt is intubated with bvm assistance(bls skill). IV slowed to tko rate(bls skill). No more drugs needed to be given(no amio or lido drip). Perfect sinus at 80, 12-lead unremarkable. Pt is now bls, correct?? Direct paramedic contact is no longer needed per a previous post or two.


Now come on, that's going just a tiny bit to far.  There is a difference between someone who experienced a severe, acute event like that and someone in the original post.

There is a difference between someone who has a high likelihood of experiencing an acute event and some in the original post.

There is a difference between someone in extremis, where a paramedic intervention won't help and someone in the original post.

The list could go on, but that should be pretty clear, yes?


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## triemal04 (Jan 7, 2012)

Veneficus said:


> But I agree with the whole first page mostly.
> 
> This patient needed a 12 lead.
> 
> ...


But *why*?  You should be one of the more qualified people to answer this, and likely have more in-hospital experience than most, so I'd like to hear.

For the sake of arguement, say that TheGodfather did a full exam, interpreted the 12-lead as well as any EM doc, etc etc, and found nothing that wasn't posted.  What was the need for a paramedic?  I'm all for taking a patient in at a higher level, even if nothing is done if talking to the doc/RN will ensure that the patient get's the care they need, but this doesn't appear to be someone like that.

I've spent a fair amount if time inside several hospitals, and the situation I laid out for what would happen on her arrival is accurate, at least from what I've seen and know.  

Patients can be much sicker than they appear, and it isn't always possible to determine that initially, but a decision does need to be made about who treats them and when it happens.  At all levels and locations.  What makes this situation so different?


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## Veneficus (Jan 7, 2012)

triemal04 said:


> But *why*?  You should be one of the more qualified people to answer this, and likely have more in-hospital experience than most, so I'd like to hear.
> 
> For the sake of arguement, say that TheGodfather did a full exam, interpreted the 12-lead as well as any EM doc, etc etc, and found nothing that wasn't posted.  What was the need for a paramedic?  I'm all for taking a patient in at a higher level, even if nothing is done if talking to the doc/RN will ensure that the patient get's the care they need, but this doesn't appear to be someone like that.
> 
> ...



Assuming all of the above.

As I said, geriatrics are a complex patient. 

They present with nonspecific symptoms. They also have complex medical and pharmaceutical interactions. The med list being too long to type sounds like a polypharmacy issue. 

In order to unravel complex patients, it takes a higher level of knowledge and understanding. While not perfect, ALS is more suited to it.

Will it require intervention most of the time during transport? Probably not. But the ability to more accurately diagnose as well as offer supportive care, makes it more beneficial to use an ALS provider than a BLS one.

Forget about the "what if scenarios" a dehydrated patient does feel better with some iv fluid.


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## triemal04 (Jan 7, 2012)

Veneficus said:


> Assuming all of the above.
> 
> As I said, geriatrics are a complex patient.
> 
> ...


I don't completely disagree with any of that, but again, from a medical standpoint, I still have to ask, "why?"  Not because this patient may or may not need anything done, but, will the paramedic be able to alter the final outcome for this patient, or even offer them a higher level of comfort?  (and yes, a patient who is dehydrated, and this could be a case depending on how long the low food intake was going on for, should get a paramedic.)

This patient should be evaluated by a paramedic, and in a better way than "your BP and pulse are fine, no ST-elevation, no acute complaint and I need to be off scene in 10 minutes so the EMT get's to take you."  And, if they are going to be turfed to a lower level than that had better be happening.  But, once it is, and nothing is found...why the need?

You said it yourself, this patient needs a higher level of care than a paramedic can offer (at the current time and for the long forseeable future), but still doesn't need any acute care, or neccasarily any comfort care.

Would this be any different than being triaged in the ER to either a fastrack unit staffed by midlevel providers, or to the main section?


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## Veneficus (Jan 7, 2012)

triemal04 said:


> I don't completely disagree with any of that, but again, from a medical standpoint, I still have to ask, "why?"  Not because this patient may or may not need anything done, but, will the paramedic be able to alter the final outcome for this patient, or even offer them a higher level of comfort?  (and yes, a patient who is dehydrated, and this could be a case depending on how long the low food intake was going on for, should get a paramedic.)
> 
> This patient should be evaluated by a paramedic, and in a better way than "your BP and pulse are fine, no ST-elevation, no acute complaint and I need to be off scene in 10 minutes so the EMT get's to take you."  And, if they are going to be turfed to a lower level than that had better be happening.  But, once it is, and nothing is found...why the need?



If you can unravel a geriatric patient and be off scene in 10 minutes, you are better than I am.

There are many things that can cause dehydration, like insensible sweating when they have the thermostat turned up to 85F for ages on end. 

But we are also entertaining the idea that the ALS provider is at the peak of ability.

I have taken a number of absolute trainwrecks out of nursing homes. Some who just needed "transport" for evaluation in the ED. (one of which was for altered labs and was in torsades when I found her) 

BUt zebras aside, it takes time to really evaluate those patients. The more eyes and minds you have on a patient longer, the better it is for the patient.   



triemal04 said:


> but still doesn't need any acute care, or neccasarily any comfort care.



I am not sure that this conclusion is supported by the presentation given.




triemal04 said:


> Would this be any different than being triaged in the ER to either a fastrack unit staffed by midlevel providers, or to the main section?



I have no use for "midlevel" providers and do not agree with this practice at all. It exists in no other nation except the USA and the healthcosts reflect its uselessness.

The only real benefit I can see with it is that it will help speed the doom of the current system and bandaides such as this can be taken off when it is inevitably, seriously, and effectively revamped.


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## Medic Tim (Jan 7, 2012)

Canada has PAs and NPs


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## triemal04 (Jan 7, 2012)

Veneficus said:


> If you can unravel a geriatric patient and be off scene in 10 minutes, you are better than I am.
> Just to be utterly clear, I meant that doing an "assessment" like that would be WRONG; more would be needed before, in good conscious and following best practice, the patient could be turfed.
> There are many things that can cause dehydration, like insensible sweating when they have the thermostat turned up to 85F for ages on end.
> Certainly; I wasn't trying to say that decreased intake was the only way, just didn't want to list everything I could think of.But we are also entertaining the idea that the ALS provider is at the peak of ability.
> ...


As I said above, most people who do this for awhile and have a decent brain will realize that some, maybe even alot, of the "stable, non-critical" patients that we take from nursing homes (or hospitals in my own experience) are anything but.  And while that is more evidence that a very sick person does not always appear as such, and that a "higher level of care" is not always what it seems, you can't base all of your future decisions off that.

At some point, good clinical judgement must come into play.  Patients can definetly fool you, and our resources in the field are somewhat limited, both in knowledge (as an entire group) and in diagnostic ability by the lack of labs, xrays, ct, etc.  For the record, I DO NOT want this to turn into an arguement about whether or not paramedics as a whole are cabable of making that type of clinical decision.  Otherwise, the only decision you can be left with is that every patient, no matter what, needs a paramedic, not only to assess them, but to be in constant attendance with them.  Because you never know, right?

To take that further, if that is an opinion that is held, then on arrival, the patient should be given every test available, for every possible problem; you never know right?  And even doctors can be fooled.  

Maybe there's a better way to put this.  If you were working in the ER, and this patient came in, and, again, saying that there was nothing else untoward found in either the physical exam or history (including evaluating their med list), what would you do for them initially?  Blood work?  A urine screening?  Maybe some fluids?  

Or would you do all of the above and then order a RN to stay with them on a 1:1 basis instead of treating them like most other relatively low (at this point)  acuity patients?  If you wouldn't do that, why the need for a paramedic to bring them in.  If you would, why?


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## Ramis46 (Jan 8, 2012)

Yeah I know that when I was a Basic that i had a paramedic start an IV ( which can be observed by a B) and put monitor on pt, but then pushed some Fentanyl. I got in trouble for atteneding the pt because after the fentanyl the pt felt good. There for i feel if you obtained 12-lead, and started an IV its a ALS call (according to our protocal). However I feel from where you are coming from. If you have ruled out everything, why cant a basic/Intermedite attend the call? really... Just like ever "sick person" that turns out to be an anxiety call... come on america...


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## Fish (Jan 8, 2012)

12Leads are so last year............ Jedi mind tricks are the new 12 Lead


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## Veneficus (Jan 8, 2012)

triemal04 said:


> As I said above, most people who do this for awhile and have a decent brain will realize that some, maybe even alot, of the "stable, non-critical" patients that we take from nursing homes (or hospitals in my own experience) are anything but.  And while that is more evidence that a very sick person does not always appear as such, and that a "higher level of care" is not always what it seems, you can't base all of your future decisions off that.
> 
> At some point, good clinical judgement must come into play.  Patients can definetly fool you, and our resources in the field are somewhat limited, both in knowledge (as an entire group) and in diagnostic ability by the lack of labs, xrays, ct, etc.  For the record, I DO NOT want this to turn into an arguement about whether or not paramedics as a whole are cabable of making that type of clinical decision.  Otherwise, the only decision you can be left with is that every patient, no matter what, needs a paramedic, not only to assess them, but to be in constant attendance with them.  Because you never know, right?



Generally I support the idea that the most complex patients need to be given the most capable provider. In the prehospital arena, that provider is the paramedic.

I am not suggesting that patients cannot be turfed, only it is best to pick and choose which ones get turfed and I do not agree that the patient initially presented meets that criteria.

It is not so much of a "you never know" mentality, as knowing that the patient has a high likehood of being a trainwreck. 

Putting aside psychomotor skills, I think that an ongoing assessment with a higher level provider, not saying the paramedic is the perfect provider, is in order in the chronically ill with nonspecific complaints.



triemal04 said:


> To take that further, if that is an opinion that is held, then on arrival, the patient should be given every test available, for every possible problem; you never know right?  And even doctors can be fooled.



Generally if the patient is admitted, a lot of tests are run. Perhaps not in the ED, but geriatric specialists are quick to point out that this is a prudent practice. A patient with a non specific compliant that cannot be diagnosed in the ED is ccertain to be admitted for this shotgun approach to testing. Particularly if the pt is an unreliable historian or has decreased mental capacity.




triemal04 said:


> Maybe there's a better way to put this.  If you were working in the ER, and this patient came in, and, again, saying that there was nothing else untoward found in either the physical exam or history (including evaluating their med list), what would you do for them initially?  Blood work?  A urine screening?  Maybe some fluids?



What to do in the ED? The easy answer is as little as possible before punting to medicine and letting them figure out things over hours or days.   



triemal04 said:


> Or would you do all of the above and then order a RN to stay with them on a 1:1 basis instead of treating them like most other relatively low (at this point)  acuity patients?  If you wouldn't do that, why the need for a paramedic to bring them in.  If you would, why?



I think you are getting a bit carried away here. 

There is a difference between dedicating a pt to basically ICU level resources and deciding that one of the lowest educated healthcare workers is not sufficent.

While it is not a very popular idea in the US yet, the paramedic is useful for more than acute care and in an aging populous, are more and more going to be called to evaluate not so much who needs emergent healthcare, but who needs healthcare in general. 

Advanced assessment also gives appropriate destination decisions. 

When you run all of your tests on an ALS ambulance and cannot find anything wrong with a geriatric patient, it doesn't mean nothing is wrong. It means the most common emergencies are not present.

It doesn't mean that this person doesn't need medical care, it means they do not need emergent medical care.

Having said that, the emergency system is the entry portal for the healthcare system in US society. The ability to use knowledge and a more advanced assessment both initially and ongoing allows earlier identification of the need for care and which care passed an ABC assessment.

The reason most elderly patients are admitted is because even the ED does not always possess the diagnostic capability or resources to handle the problems of this patient group. It does not mean they do not need medical care and it does not mean they need an ICU.

I listed dehydration, because it does not often require emergent treatment. But still needs to be treated. I guess I should have been more clear as to why. 

The early identification and timely intervention of nonacute healthcare problems is warrented in the geriatric population. Care does not end at the ED but it often begins in the field. As we see more and more people unable to have access to primary care, this population will grow. 

A paramedic will not have all the diagnostics or treatments for nonacute healthcare issues. But they will have more knowledge and better critical thinking skills than an ABC assessment.

In the future I also expect to see both treat and release as well as alternate destinations as a standard of US EMS practice just like it is in other nations out of financial necessity.

Unfortunately, my opinion is that the modern geriatric patient population, especially with chronic vs. acute illness, is just too complex of a patient for a basic to do an appropriate assessment on. 

I also think that the assessment needs to be more inclusive than just "you are not having a heart attack or stroke, and therefore just need a taxi ride to somebody who can figure this out." But a more indepth and ongoing assessment can be done on the way to the hospital.

When you have the flu, the intervention a doctor performs is rather minimal, if any at all. But it is the assessment that nothing more serious is going on than that. 

The same applies for prehospital care. There is a reason certain procedures and assessment decisions have age ranges on them. If you notice, they are usually based around extremes of age. 

That does not go away in the hospital. As 1 example, a suspeced if not diagnosed pneumonia patient (regardless of acuity) who is over the age of 65 is going to a floor, or if bad ICU. They are not getting amoxicillin with instructions to come back if things worsen.  

Would you put a patient you were certain would get admitted in the back of a taxi that had an AED?


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## Veneficus (Jan 8, 2012)

TheGodfather said:


> I recently got in trouble for performing [what I feel is] good standard patient care on a patient I had recently. I'll give the scenario(1), my interventions(2), and what my agency's argument against me was (3)
> 
> ***note: don't get too hung up on the nitty gritty of the patient care/status/etc, that's not the point; I'm going to be really brief***
> 
> ...



Some things to consider in red


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## Remeber343 (Jan 8, 2012)

Vene, Im sorry the emts you work with are only really first responders in your eyes. Our area must be fortunate to have such decent emts that can actually do assessments and such. Maybe if you were to educate them instead of talk down it would change things?

And what exactly do you find disturbing about the patients vitals?


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## Veneficus (Jan 8, 2012)

Remeber343 said:


> Vene, Im sorry the emts you work with are only really first responders in your eyes. Our area must be fortunate to have such decent emts that can actually do assessments and such. Maybe if you were to educate them instead of talk down it would change things?
> 
> And what exactly do you find disturbing about the patients vitals?



I think you misunderstand me. 

It is not the fault of the individual EMTs for the curriculum they are taught and held to. Even the latest update is grossly over simplified, skill based, and taught as unconnected facts to be memorized.

It is not fair to hold people accountable for what they were never exposed to. 

The discussion also has to assume the mean level of EMT, not exceptional ones, or ones with other backgrounds.

To "educate" these providers, while many do there best here, you are talking about discussing mutliple topics and how to integrate them over hundreds of hours.

It would just be easier to send them to medic class. Even with its insufficencies, it produces capable providers.

What do I find disturbing about these vitals?

A decreased mobility patient with too many meds to list and with elevated BP, wa pulse that is elevated and nearly tachy, is not right. 

Further increases in compensatory mechanisms may be chemically limited, (b-blockers, ace inhibtors, thyroid suppression, etc) which hides an underlying acute pathology or exacerbation of a chronic one.

While there exists the possibility that there is some level of anxiety in the patient causing it, that is a diagniosis of exclusion warrenting a more detailed assessment.  

"Assessment is not solving a mystery, it is an interrogation for which there must be a confession."

-Me


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## usalsfyre (Jan 8, 2012)

Remeber343 said:


> Vene, Im sorry the emts you work with are only really first responders in your eyes. Our area must be fortunate to have such decent emts that can actually do assessments and such. Maybe if you were to educate them instead of talk down it would change things?


Can't speak for Vene, but I've yet to meet an EMT who could present an assessment as anything other than "really sick, needs to go right now", "maybe some really vague (neuro, "heart") issue going on and might need to go" or "stupid and waste of my time". They frequently get the last two mixed up. Very, very rarely can they narrow it down further than a general body system (cholecystitis and not "GI problems"). Come to think of it though, thats a lot of paramedics too...


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## Veneficus (Jan 8, 2012)

I have met the whole gambit, but for general discussion, I try to refer to the mean.


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## UKMEDICARABIA (Jan 10, 2012)

TheGodfather said:


> I recently got in trouble for performing [what I feel is] good standard patient care on a patient I had recently. I'll give the scenario(1), my interventions(2), and what my agency's argument against me was (3)
> 
> ***note: don't get too hung up on the nitty gritty of the patient care/status/etc, that's not the point; I'm going to be really brief***
> 
> ...


As a clinician there are 2 things that can potentially land you in court.

1) Doing something you should not have done...
2) NOT doing something you SHOULD have done.

The former would never relate to doing a 12 lead ECG.
The latter is impossible to defend in court.

You have the equipment and skill to carry out and interpret the ECG. The fact that you CAN do it means that if anyone involved in the care of this patient SHOULD have done it then that person should have been you!

Your agency is treading into murky waters by suggesting otherwise.  it may be that they want to justify the end decision and not doing an ecg supports their view of what decision should have been taken.  ask them to put their comments in writing... and file away that piece of paper...somewhere safe.

you made a good call.


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## triemal04 (Jan 13, 2012)

Veneficus said:


> Generally if the patient is admitted, a lot of tests are run. Perhaps not in the ED, but geriatric specialists are quick to point out that this is a prudent practice. A patient with a non specific compliant that cannot be diagnosed in the ED is ccertain to be admitted for this shotgun approach to testing. Particularly if the pt is an unreliable historian or has decreased mental capacity.
> 
> What to do in the ED? The easy answer is as little as possible before punting to medicine and letting them figure out things over hours or days.


Sure, I was being more facetious to prove a point that, either you can use some independant thought along with tests, or ONLY base your decisions of what a test tells you.

Which is really my point.  I understand your opinion that the more difficult patients should be in the care of the provider who is better equipped to deal with them, in this case a paramedic, but, as you said, there isn't much that will be done right away for this patient; their problem will take time to resolve, and are, at present, relatively stable.


Veneficus said:


> I think you are getting a bit carried away here.
> 
> There is a difference between dedicating a pt to basically ICU level resources and deciding that one of the lowest educated healthcare workers is not sufficent.
> 
> While it is not a very popular idea in the US yet, the paramedic is useful for more than acute care and in an aging populous, are more and more going to be called to evaluate not so much who needs emergent healthcare, but who needs healthcare in general.


No, I'm not.  It's the best analogy I can come up with, and it's really not to bad.  I'm not saying that the RN would need to do anything more for that patient other than sit and talk and perhaps come up with a better history, which is what the paramedic would be doing on the way in, just that, by your reasoning it would appear that you should want an RN with them.  After the patient has been appropriately assessed (just pretend that this would be done prehospital as well) you have two choices: letting a low level provider sit with the patient while having a higher level provider available in a timely manner, or have the higher level provider be with them constantly ; that's before you arrive at the ER.  After you arrive, after the patient has been assessed, you have the choice of either having nobody sit with the patient (I suppose you could stick a CNA with them) and a higher provider available in a timely manner, or having a higher level provider, in this case a RN, constantly with the patient.  While not the perfect comparison, it is valid.

The paramedic COULD be useful for more than acute care (many allready are, but I mean nationally), but at present aren't.  Yes, things should head in that direction but currently haven't.  It doesn't change the situation at hand though; while this lady needed to be evaluated and treated by a MD (or PA/NP even though you dislike them, or a paramedic with the ability and education to prescribe and refer etc etc) this was not someone who medically needed constant supervision by the highest available medical personell.


Veneficus said:


> When you run all of your tests on an ALS ambulance and cannot find anything wrong with a geriatric patient, it doesn't mean nothing is wrong. It means the most common emergencies are not present.
> 
> It doesn't mean that this person doesn't need medical care, it means they do not need emergent medical care.


Absolutely, just because I can't figure out what, if anything is wrong with someone doesn't mean that there isn't something wrong.  But, that failure to reach a diagnosis does not mean that every patient that happens to needs me, or another paramedic riding with them.  Some will do just fine with an EMT.  Some won't.  It depends on a lot of things. 

As you said though; they don't need emergent care.  And possible, depending on the patient, they don't need any care I can provide them beyond a ride to someone who can.  Though there are many more factors that come into play that I'm not listing, but when that is the situation...


Veneficus said:


> Having said that, the emergency system is the entry portal for the healthcare system in US society. The ability to use knowledge and a more advanced assessment both initially and ongoing allows earlier identification of the need for care and which care passed an ABC assessment.
> 
> The reason most elderly patients are admitted is because even the ED does not always possess the diagnostic capability or resources to handle the problems of this patient group. It does not mean they do not need medical care and it does not mean they need an ICU.
> <snip>
> ...


They will.  As I said, I'm all for taking someone in who I won't be doing anything for if what I've found in my history/exam will potentially speed up there care once it get's reported.  As presented, I don't see this as being the case.  There are things that are concerning, but even an EMT can be told to be sure to pass these on, and in this case the paramedic would still be right there if it didn't happen.  Remember, this isn't like immedietly turfing the patient, but only doing so after a thourogh assessment, and relaying that to the EMT.


Veneficus said:


> In the future I also expect to see both treat and release as well as alternate destinations as a standard of US EMS practice just like it is in other nations out of financial necessity.
> 
> Unfortunately, my opinion is that the modern geriatric patient population, especially with chronic vs. acute illness, is just too complex of a patient for a basic to do an appropriate assessment on.


Again, I don't really disagree.  I'd like to see the US move in that direction, both by upping the education required and then increasing the responsibility and accountability of the providers.  And, while an EMT isn't completely capable of assessing all patients, they aren't needed to in this situation; a paramedic has allready assessed the patient.  The EMT should still do there own, but a (hopefully) better eval has been done with the results reported and/or written down for the EMT to pass on to the recieving facility.  And yes, this should be a better assessment than "no stroke no heart attack."  If it takes a couple minutes longer...so what?


Veneficus said:


> The same applies for prehospital care. There is a reason certain procedures and assessment decisions have age ranges on them. If you notice, they are usually based around extremes of age.
> 
> That does not go away in the hospital. As 1 example, a suspeced if not diagnosed pneumonia patient (regardless of acuity) who is over the age of 65 is going to a floor, or if bad ICU. They are not getting amoxicillin with instructions to come back if things worsen.
> 
> Would you put a patient you were certain would get admitted in the back of a taxi that had an AED?


I suppose I could come up with a situation where I would do that that, but really, no they'd go in by ambulance.  I don't think that admission to the hospital can be the decider for who will take a patient though.  You said it above, people will get admitted for many reasons, valid and appropriate, and sometimes not.  And again, because someone is admitted does not mean that they need immediate or even quick treatement, just continual care that is not available outside a hospital.

I think this is just going around in circles at this point.  What I know/have seen/done colors my side, and the same will apply to you.  I understand your feeling about why a patient like this should be handled by a paramedic, and in many situations it probably is the correct one, for many lousy reasons.  I just don't agree, for many lousy reasons.


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