# EMT Scope of Practice and Private BLS companies policy



## Mammaoftwins04 (Sep 5, 2011)

My company policy on ALS calls is to load and go if the facility is within 5 mins. However, it contradicts L.A. County scope of practice. I recently was on a call for a Low H and H to the E.R. on a Sunday, from a SNF. The patient was clearly an ALS call and there was no ER within 5 mins. I refused to transport, her v/s were BP-64/40, Cool clammy and diaphoretic, A/O- o, and tachy. This patient is a regular of mine and she is normally BP systolic 160-180 A/O 4 and able bodied. The facility refused to call als, ofcourse and I called fire. The facility staff R.n. canceled fire on scene and another bls company transported the pt, with vitals under systolic bp of 50/30. She didnt make it to the hospital alive. I reported the facility to DHS and the EMS agency, and I was fired for depriving her of ALS care, by not transporting. No regrets, other than not putting on my gurney and waiting for fire out front.:sad:


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## bigdogems (Sep 5, 2011)

Just going off what I read there are issues... How far was the nearest hospital. You just admitted that you refused to transport the pt. Was this because transporting would have gone against a company rule? How much extra time had passed between you making pt contact and another company getting to the hospital with the pt? How much sooner have you could of had her to the hospital? If you truely refused to transport the pt because you werent comfortable and it wouldnt have been against company policy you may want to be happy that all that has happened was being fired.

Now you did also state what else could have been done. I have had facilities that refused to allow municipal ems to come. I have called and met them outside where the facility no longer has a say so


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## Cup of Joe (Sep 5, 2011)

ALS intercept could have been an option, given the facility's actions.  Even if it was a block away.


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## JPINFV (Sep 5, 2011)

What was your estimated transport time to the closest emergency department? 

...and yes. As someone who worked in Orange County, which has essentially the same transport policy (estimated transport time to emergency department vs ETA of fire. However OC LEMSA has gone further, unfortunately, and set specific vital sign criteria), the standard procedure at the company I worked for was to call 911 for paramedics (pro tip: Just ask to borrow the phone. Don't tell them you're calling 911 until the number is actually dialed) and try to meet them outside in the ambulance if possible.


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## DESERTDOC (Sep 5, 2011)

Did you document all of your findings on your patient care report?  Did you point out the unstable patient to your managers?  Did you take your report to the LEMSA?  Did you contact the California State EMS Authority?  Was there an ALS unit available from your company? 

Did you contact medical control, and let them know what was going on?


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## JPINFV (Sep 5, 2011)

DESERTDOC said:


> Did you document all of your findings on your patient care report?  Did you point out the unstable patient to your managers?  Did you take your report to the LEMSA?  Did you contact the California State EMS Authority?  Was there an ALS unit available from your company?
> 
> Did you contact medical control, and let them know what was going on?




Not all companies in LACo run paramedics, and we don't know which company the OP was from. 

Similarly, while I'm not sure about LACo, private companies in OC (which are all BLS) are neither assigned to a base station nor equipped to contact online medical control. With how similar OC and LA are, this wouldn't surprise me if LA was set up in a similar manner.


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## bigdogems (Sep 5, 2011)

Similarly, while I'm not sure about LACo, private companies in OC (which are all BLS) are neither assigned to a base station nor equipped to contact online medical control. With how similar OC and LA are, this wouldn't surprise me if LA was set up in a similar manner.[/QUOTE]

I have no idea how things work in CA but how do they get away with not having the option of online medical control?


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## DESERTDOC (Sep 5, 2011)

JPINFV said:


> Not all companies in LACo run paramedics, and we don't know which company the OP was from.
> 
> Similarly, while I'm not sure about LACo, private companies in OC (which are all BLS) are neither assigned to a base station nor equipped to contact online medical control. With how similar OC and LA are, this wouldn't surprise me if LA was set up in a similar manner.



Ok, thank you, good info I was not aware of.  So, BLS providers where you are do not have any form of medical control?

To the OP, did you call and speak to a field sup. as this scene was unfolding and explain in real time exactly how unstable the patient was?


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## thegreypilgrim (Sep 5, 2011)

All kinds of confusion here.



Mammaoftwins04 said:


> My company policy on ALS calls is to load and go if the facility is within 5 mins. However, it contradicts L.A. County scope of practice.


 LA County has a policy on this listed in Ref. 808 (among other places):

_In life-threatening situations in which the estimated time of arrival (ETA) of the paramedics *exceeds* the ETA to the most accessible receiving facility (MAR), EMT-1's shall exercise their judgment as to whether it is in the patient's best interest to be transported prior to the arrival of the paramedics._

They don't quantify the time interval, it doesn't have to be >5 minutes. It's only a judgment, and this policy trumps that of any individual provider.



> I refused to transport, her v/s were BP-64/40, Cool clammy and diaphoretic, A/O- o, and tachy. This patient is a regular of mine and she is normally BP systolic 160-180 A/O 4 and able bodied.


 If Fire's ETA to you was less than your ETA to the nearest hospital this would have been appropriate, and should have been the basis of your argument. If not, then why not just transport?


> The facility refused to call als, ofcourse and I called fire. The facility staff R.n. canceled fire on scene and another bls company transported the pt, with vitals under systolic bp of 50/30.


 This is very odd. Fire did not even assess the patient? Since the call didn't originate from the SNF itself, I'm not all that clear as to whether or not Fire had the right to access the patient (especially if it was a privately owned facility, which I'm guessing this was) so I can't really comment on this further. Did you remain on scene after they left though? If so, and it was clear they were not going to transport the patient, why not just go ahead and transport anyway since the whole thing is just a lost cause? Why wait for another private company to arrive?


> She didnt make it to the hospital alive. I reported the facility to DHS and the EMS agency, and I was fired for depriving her of ALS care, by not transporting. No regrets, other than not putting on my gurney and waiting for fire out front.:sad:


 I don't know what to tell you without more info. Seems like a messed up situation, though. Welcome to EMS in LA.


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## thegreypilgrim (Sep 5, 2011)

bigdogems said:


> I have no idea how things work in CA but how do they get away with not having the option of online medical control?


 Everything in the LACo EMT Scope is the equivalent of a standing order. There's nothing for them to contact medical control for.


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## bigdogems (Sep 5, 2011)

thegreypilgrim said:


> Everything in the LACo EMT Scope is the equivalent of a standing order. There's nothing for them to contact medical control for.



Wow. I understand that as a basic you'd have to try really hard to kill a pt but to me thats kinda scary. I currently have everything as a standing order but there is still the option of picking up a phone if we run into a issue. Is that just a rule for basics or all levels in LA county?


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## thegreypilgrim (Sep 5, 2011)

bigdogems said:


> Wow. I understand that as a basic you'd have to try really hard to kill a pt but to me thats kinda scary. I currently have everything as a standing order but there is still the option of picking up a phone if we run into a issue. Is that just a rule for basics or all levels in LA county?


 I wish it were for all levels, but sadly no. For ALS only the most basic of interventions are by protocol, you need a base hospital (medical control) order for nearly everything - and they usually deny permission anyway. The EMT Scope is incredibly limited anyway, really there's no way you could possibly harm someone with it if you tried. It's limited to oxygen, oral glucose, and ability to "assist" patients in taking their own prescribed NTG, albuterol MDI, or Epi-Pen. That's it.


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## bigdogems (Sep 5, 2011)

Another question on the OP. Did you provide care until the second private company showed up?


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## JPINFV (Sep 5, 2011)

bigdogems said:


> I have no idea how things work in CA but how do they get away with not having the option of online medical control?





All 911 calls, to the best of my knowledge, receive a paramedic first response.
In the populated regions, you can't throw a rock without hitting either a fire station with a paramedic unit (be it engine, truck, ambulance, or squad) or an emergency department (OC has a little under 790 sq miles, of which about 1/4th is rural (unincorporated parts of South Eastern OC, and over 30 emergency departments).
The EMT scope of practice when I worked there was pretty much limited to oxygen and transport for medical patients. I believe they've added oral glucose since then. Everything is standing orders.
Ultimately, I have little faith in EMTs who need medical control with such a limited scope. If medical control is needed, either a paramedic or an emergency department is needed. ****ing around with online medical control because the EMT is incompetent or incapable of making a "call 911 for paramedics or initiate emergency transport"  decision (which doesn't apply to the OP) delays both transport or requesting paramedics.


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## JPINFV (Sep 5, 2011)

DESERTDOC said:


> Ok, thank you, good info I was not aware of.  So, BLS providers where you are do not have any form of medical control?
> 
> To the OP, did you call and speak to a field sup. as this scene was unfolding and explain in real time exactly how unstable the patient was?



As I mentioned in my prior post (directed at a different poster with the same question), no. 

Additionally, what would contacting a supervisor (who has no actual authority over an active call he is currently not on anyways) do besides delay either calling 911 or transporting the patient?


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## DESERTDOC (Sep 5, 2011)

JPINFV said:


> As I mentioned in my prior post (directed at a different poster with the same question), no.
> 
> Additionally, what would contacting a supervisor (who has no actual authority over an active call he is currently not on anyways) do besides delay either calling 911 or transporting the patient?



Well, on some level the supervisor did have authority as it related to the OP's job.  While the OP may have done right by county policy, the OP cost the company money.  And as the OP has only one post, this thread, and has not returned to what would surely be a hot-button topic it is interesting to me that they did not hang around to answer questions.


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## bigdogems (Sep 5, 2011)

I think DESERTDOC asked about a supervisor on the basis that this pretty much sounds like a cluster. IMO the once I found out the facility was refusing to allow ALS I would have loaded and transported. But if they're refusing ALS and the poster was refusing to transport I'd say thats a situation for a supervisor to be made aware of. And in this case your not delaying care because they already made the decision not to transport. Im sure there are alot of small details not in the OP but it sounds like the call could be subject to some major legal actions. Especially if family decides to start asking questions. Like I said in my first place. If getting fired was all that happened they may want to be thankful.


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## JPINFV (Sep 5, 2011)

DESERTDOC said:


> Well, on some level the supervisor did have authority as it related to the OP's job.  While the OP may have done right by county policy, the OP cost the company money.  And as the OP has only one post, this thread, and has not returned to what would surely be a hot-button topic it is interesting to me that they did not hang around to answer questions.




...but the supervisor can't order the OP to violate county EMS policy (akin to any other regional or state wide protocol/policy) and, ultimately, the OP would be on the hook for any orders given by the supervisor off scene. Sure, advise and consult, but this does not sound like a situation where simple advise was needed. 

Also, this thread is less than an hour old. The OP might be back.


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## DESERTDOC (Sep 5, 2011)

JPINFV said:


> ...but the supervisor can't order the OP to violate county EMS policy (akin to any other regional or state wide protocol/policy) and, ultimately, the OP would be on the hook for any orders given by the supervisor off scene. Sure, advise and consult, but this does not sound like a situation where simple advise was needed.
> 
> Also, this thread is less than an hour old. The OP might be back.



No they cannot order, that is why she should have gotten them involved from the start.  The supervisor know's they cannot counter-mand county policy.  Then it falls on the supervisor to do their job and help guide employees through a cluster of a call.  If this is not the case, then I think the employee losing her job is a blessing in the long run.

Crappy spot to be in with no medical control and no support from the company you work for?  Sure, sign me up, two each please.


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## DrParasite (Sep 5, 2011)

Please allow me to go over this piece by piece:


Mammaoftwins04 said:


> My company policy on ALS calls is to load and go if the facility is within 5 mins. However, it contradicts L.A. County scope of practice.


not knowing the policy, I'll have to take your word for it.  but question, which is in the best interests of the patient?





Mammaoftwins04 said:


> I recently was on a call for a Low H and H to the E.R. on a Sunday, from a SNF.


what's an Low H and H?





Mammaoftwins04 said:


> The patient was clearly an ALS call and there was no ER within 5 mins. I refused to transport, her v/s were BP-64/40, Cool clammy and diaphoretic, A/O- o, and tachy.


No.  the patient was clearly sick, and in need of ALS.  it was not an ALS call, as there was no ALS available at that time.  But the patient was sick, and needed ALS.





Mammaoftwins04 said:


> This patient is a regular of mine and she is normally BP systolic 160-180 A/O 4 and able bodied.


so your normally healthy patient is circling the drain, sounds serious, sounds like she needs help.





Mammaoftwins04 said:


> The facility refused to call als, of course and I called fire.


why???? if they are refusing to call ALS, and they are the higher level of medical authority, who are you to question them?  (I will get back to this point below).  in fact, all you are going to do is piss them off.





Mammaoftwins04 said:


> The facility staff R.n. canceled fire on scene


so the higher medical authority cancelled Fire, which is his or her right (not that they are right or wrong, just within their rights).  write and incident report and let your management deal with it after the call.





Mammaoftwins04 said:


> and another bls company transported the pt, with vitals under systolic bp of 50/30. She didnt make it to the hospital alive.


so you delayed transport, delayed the patient recieving any ALS care.  how did that benefit the patient?


Mammaoftwins04 said:


> I reported the facility to DHS and the EMS agency, and I was fired for depriving her of ALS care, by not transporting.


and probably rightfully so





Mammaoftwins04 said:


> No regrets, other than not putting on my gurney and waiting for fire out front.:sad:


you are half right.  you should have put her on your gurney, and started heading to the hospital.  if you could meet up with fire/ALS, great, if not, head to the hospital.  bonus points if you have your dispatch call the ER and tell them you are coming in with a sick patient, and need a bed waiting for you.

The patient is sick, no one is arguing that, but you are in the nurse's home, so she is the highest level of medical authority.  so until you leave her care, it's her call, and getting into a pissing match doesn't solve anything, and is in fact detrimental to patient care, because it delays the patient's access to definitive medical care and advance life support, which your patients seems to need.  now once you leave the doors, you are the highest level of care, and if, in your mind, the situation changes, then call ALS (and be 100% in the right, both in the patient's advocate point of view and in the political point of view).

remember, the name of the game is to get the sick patient to definitive care.  and if the ER is closer than the nearest ALS, just go to the ER, or meet ALS en route.


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## JPINFV (Sep 5, 2011)

DESERTDOC said:


> No they cannot order, that is why she should have gotten them involved from the start.  The supervisor know's they cannot counter-mand county policy.  Then it falls on the supervisor to do their job and help guide employees through a cluster of a call.  If this is not the case, then I think the employee losing her job is a blessing in the long run.
> 
> Crappy spot to be in with no medical control and no support from the company you work for?  Sure, sign me up, two each please.




What would you have expected online medical control or a supervisor to say in this situation to say that isn't already covered by written policy? This isn't even touching on the issue of the professional responsibility of every provider to know what the policies and protocols are for their specific system. In my mind, it's as much the provider's responsibility to know what the system's policies are as the companies. 

/insert rant on EMS wanting to be a profession without any of the associated individual responsibilities of being a professional.


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## DESERTDOC (Sep 5, 2011)

I have clearly stated the reasoning and need for a sups involvement in this specific case.  I suspect the RN on scene was pissed, and contacting a sup and explaining what was going on would go a long way to smooth ruffled feathers and gain needed advice.  

Others will not call a sup to explain what is/s was going on.   I would.


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## JPINFV (Sep 6, 2011)

DrParasite said:


> what's an Low H and H?


Hematocrit and hemoglobin.



> if they are refusing to call ALS, and they are the higher level of medical authority, who are you to question them?  (I will get back to this point below).


Can a "higher medical authority" (which is debatable in this situation for a variety of reasons) order an EMS provider to take a patient that is out of their scope of practice when an appropriate level of care is readily and quickly accessible through the 911 system? Personally, I say no. That is not a valid order, and as such, should be ignored. If the 911 operator informs the EMT crew of an extended ETA for the nearest paramedic unit, then transport is indicated under policy, not because a SNF nurse so orders it. 

Can a SNF nurse order an EMT crew to transport a vent dependent patient on a non-emergency call (be it interfacility, or simply not falling under the "the patient is about to die and transport time is less than paramedic ETA" exemption")? 



> in fact, all you are going to do is piss them off.


In a situation like this, this is the least of my concerns. However, if I'm going to make the staff mad at either the receiving or transferring facility, I need to have a reasonable articulable reason to do so. Based on the case as presented, that should be a very very low bar to reach. Of course every decision we make should have a reasonable articulable reason. 




> so the higher medical authority cancelled Fire, which is his or her right (not that they are right or wrong, just within their rights).



In what system is it allowable for non-EMS entities to cancel the request for paramedics from an EMS entity? 



> and probably rightfully soyou are half right.  you should have put her on your gurney, and started heading to the hospital.
> 
> if you could meet up with fire/ALS, great, if not, head to the hospital.  bonus points if you have your dispatch call the ER and tell them you are coming in with a sick patient, and need a bed waiting for you.


EMS systems in urban Southern California does not engage in rolling  rendezvous. However, to be honest, I do question the validity of a pure  ETA vs ETA comparison. Arguably a patient is better off if it was a  paramedic ETA + 5 minutes vs ED ETA.  



> The patient is sick, no one is arguing that, but you are in the nurse's home, so she is the highest level of medical authority.  so until you leave her care, it's her call,


Once care is transported to the EMT crew, which is done upon receiving report, it is no longer the nurse's call. It is the EMT crew's patient, and the EMT crew's decision to avail themselves to the appropriate available resources, including requesting paramedics. The nurse, while potentially a good source of information, does not hold veto over an EMS crew's treatment decision, including destination choice. To say that the nurse can veto a request for paramedics would be to equally say that the nurse can veto a decision to reroute to the nearest emergency department. Both are not valid decisions for the nurse to make for the EMS crew. 




> and getting into a pissing match doesn't solve anything, and is in fact detrimental to patient care, because it delays the patient's access to definitive medical care and advance life support, which your patients seems to need.  now once you leave the doors, you are the highest level of care, and if, in your mind, the situation changes, then call ALS (and be 100% in the right, both in the patient's advocate point of view and in the political point of view).



For someone championing rapid transport or access to paramedics, I find it strange that you would suggest delaying paramedics while the patient is finished being assessed, packaged, and moved to the ambulance. If a patient is critical, and this sounds like one of those cases where a doorway assessment indicates a need for paramedics, then the time taken up by completing a basic assessment, packaging, and moving to the ambulance would best be done with a concurrent response by paramedics. By waiting for all of those to be done, you've delayed a paramedic response without need nor reason.


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## JPINFV (Sep 6, 2011)

DESERTDOC said:


> I have clearly stated the reasoning and need for a sups involvement in this specific case.  I suspect the RN on scene was pissed, and contacting a sup and explaining what was going on would go a long way to smooth ruffled feathers and gain needed advice.
> 
> Others will not call a sup to explain what is/s was going on.   I would.



I have no problem with a supervisor following up after a call. I have issues with delaying either requesting paramedics or delaying transport in order to involve a supervisor with what should be a generally straight forward call.


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## DrParasite (Sep 6, 2011)

JPINFV said:


> Can a "higher medical authority" (which is debatable in this situation for a variety of reasons) order an EMS provider to take a patient that is out of their scope of practice when an appropriate level of care is readily and quickly accessible through the 911 system? Personally, I say no. That is not a valid order, and as such, should be ignored. If the 911 operator informs the EMT crew of an extended ETA for the nearest paramedic unit, then transport is indicated under policy, not because a SNF nurse so orders it.


good question.  can't give you an answer.  probably something to be discussed not in the heat of the moment by people who get paid more than I.





JPINFV said:


> In a situation like this, this is the least of my concerns. However, if I'm going to make the staff mad at either the receiving or transferring facility, I need to have a reasonable articulable reason to do so. Based on the case as presented, that should be a very very low bar to reach. Of course every decision we make should have a reasonable articulable reason.


haven't we been through this before?  when you work for a private company, many employers will fire the employee to maintain the contract, despite the employer being right.  Sometimes the right thing to do has to be modified to fit the situation, which is why you sometimes need to be a little sly, or call for a supervisor who will take the heat for doing what's right, even if the SNF doesn't want it done (but no, I wouldn't have waited for a supervisor).  but I also need my job to allow my family to eat and live in a home.


JPINFV said:


> In what system is it allowable for non-EMS entities to cancel the request for paramedics from an EMS entity?


well, apparently in the OP's system they can.  

I also know doctors who will only request BLS when they request an ambulance for chest pain or difficulty breathing.  I also know of cases where the doctor cancelled ALS when they arrived.  usually it is not done without the BLS's consent, or if the BLS did object the ALS would stay, but it has been done.





JPINFV said:


> EMS systems in urban Southern California does not engage in rolling  rendezvous. However, to be honest, I do question the validity of a pure  ETA vs ETA comparison. Arguably a patient is better off if it was a  paramedic ETA + 5 minutes vs ED ETA.


 hmm, did not know that.  apparently EMS in the NorthEast/MidAtlantic US and SoCal do things very differently.


JPINFV said:


> Once care is transported to the EMT crew, which is done upon receiving report, it is no longer the nurse's call. It is the EMT crew's patient, and the EMT crew's decision to avail themselves to the appropriate available resources, including requesting paramedics. The nurse, while potentially a good source of information, does not hold veto over an EMS crew's treatment decision, including destination choice. To say that the nurse can veto a request for paramedics would be to equally say that the nurse can veto a decision to reroute to the nearest emergency department. Both are not valid decisions for the nurse to make for the EMS crew.


I would argue that while the patient is in the SNF bed, it is still the nurse's call.  in fact, until the patient is on the EMT crew's bed and all paperwork signed and report given, than the patient is not longer under the care of the nurse.  Further, in almost every IFT I have done, the destination was decided before I walked into the room.  The doctor (who actually authorized the trip) wants a certain facility, if you are going to over ride the doctor, you better have a really good reason, and the nurse is, in fact, acting on behalf of the doctor.


JPINFV said:


> For someone championing rapid transport or access to paramedics, I find it strange that you would suggest delaying paramedics while the patient is finished being assessed, packaged, and moved to the ambulance. If a patient is critical, and this sounds like one of those cases where a doorway assessment indicates a need for paramedics, then the time taken up by completing a basic assessment, packaging, and moving to the ambulance would best be done with a concurrent response by paramedics. By waiting for all of those to be done, you've delayed a paramedic response without need nor reason.


based on this description, I think you are right.  If I was in the EMT's place, I would have been there and gone in, picked up the patient, and been gone in under 10 minutes.  if the facility is giving me crap about calling for ALS, than I would have put the patient on my cot, and started walking out the door, calling for ALS once I got out the door, especially since they already cancelled them once.

The wrong move was not transporting the patient, as it was detrimental to the patient's condition.  Sometimes you got to work within the confines and political limitations of the system, despite wishing I could do otherwise.


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## JPINFV (Sep 6, 2011)

DrParasite said:


> well, apparently in the OP's system they can.


Being allowable or not and being possible are two different things. It's like saying that murder is allowable because it's done. One issue does not follow the other. 





> Further, in almost every IFT I have done, the destination was decided before I walked into the room.  The doctor (who actually authorized the trip) wants a certain facility, if you are going to over ride the doctor, you better have a really good reason, and the nurse is, in fact, acting on behalf of the doctor.


I agree that a good reason is needed, be it patient request or medical necessity. I don't think anyone is going to argue that a medical necessity was not present in a case like this to reroute if needed.


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## Mammaoftwins04 (Sep 6, 2011)

*more details on scope of practice incident*

The incident was in Sylmar , Ca. La City Fire are the responders for that area. The nearest ER was Olive View, which going code 3, takes 12-15 minutes. I've gone code 3 there before with a pt. from this same facility, and was threatened by ER staff that if I ever decided to "load and Go" again with an ALS pt, They would report me. I was an attendant then. I also worked for a BLS company and we have different rules on driving code 3, which delays the emergency transport. We cant drive code on the freeway, if we come to a blocked intersection we have shut everything down, obey all speed limits and we don't have an ALS unit following us. This particular facility has been shut down 3 times prior for excessive violations. I have been called to transport a pt, and arrived to find my pt. pulseless, fixed pupils, with dependent lividity setting in. No exaggeration! Sorry I wasn't more specific, this wasn't my first time with this dilemma, it just seems like hospitals and facilities loved to pawn off ALS patients to us BLS units all the time, it just gets really old! Oh, and the hospital she was supposed to go was USC county.


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## JPINFV (Sep 6, 2011)

Mammaoftwins04 said:


> and was threatened by ER staff that if I ever decided to "load and Go" again with an ALS pt, They would report me.



...and this is why I carried the OC LEMSA transport policy in clipboard and have, on occasion, ran off copies that were handed to the staff with my PCR. 



> We cant drive code on the freeway,


So you can't drive 65 mph on a freeway when everyone else is going 80? Sounds reasonable. 



> if we come to a blocked intersection we have shut everything down,


So you can't force vehicles, which don't have the benefits of a flashing lights, into an intersection against a red light and into on-coming traffic? Sounds reasonable. The better option when faced with backed up traffic at a red light is to switch to the opposite lanes of traffic, which should be clear. 



> obey all speed limits and we don't have an ALS unit following us.


Increased speed doesn't save much time anyways. Actually, lights and sirens generally don't save much time either.


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## Mammaoftwins04 (Sep 6, 2011)

*Easy for your to say! Have you ever worked for a BlS company?*

Because if you had, you would know that we can't drive against traffic either! Do you still work, or are you at home on your computer for a living?


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## Mammaoftwins04 (Sep 6, 2011)

Must be nice to know everything at 26. Youngster.


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## JPINFV (Sep 6, 2011)

Mammaoftwins04 said:


> Because if you had, you would know that we can't drive against traffic either! Do you still work, or are you at home on your computer for a living?




Yes, I worked for two years for Lynch down in OC during undergrad. OMS2= Osteopathic Medical Student year 2. Thanks for playing. 

Just because your company is putting restrictions (and the unable to go against traffic is a nonsensical one) doesn't mean you aren't legally exempt from that section of the traffic code (which you are) (Reference: CVC 21055 exempts emergency vehicles displaying a forward facing steady red lamp from CVC chapter 3).


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## JPINFV (Sep 6, 2011)

Mammaoftwins04 said:


> Must be nice to know everything at 26. Youngster.



Nice to know that you're only bone of contention is my age and not something of actual substance.


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## Mammaoftwins04 (Sep 6, 2011)

Age is an important factor when considering life experience.


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## JPINFV (Sep 6, 2011)

If "life experience" makes me indecisive and makes me arrogant enough to disregard what other people are saying for no actual reason, then I hope never to obtain "life experience."


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## usalsfyre (Sep 6, 2011)

Having worked in urban, suburban and rural I have yet to find an area where running code provides any consistent, significant time savings.

Of course I'm only 28, so I guess my EMS experience doesn't count...


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## Akulahawk (Sep 6, 2011)

Mammaoftwins04 said:


> My company policy on ALS calls is to load and go if the facility is within 5 mins. However, it contradicts L.A. County scope of practice. I recently was on a call for a Low H and H to the E.R. on a Sunday, from a SNF. The patient was clearly an ALS call and there was no ER within 5 mins. I refused to transport, her v/s were BP-64/40, Cool clammy and diaphoretic, A/O- o, and tachy. This patient is a regular of mine and she is normally BP systolic 160-180 A/O 4 and able bodied. The facility refused to call als, ofcourse and I called fire. The facility staff R.n. canceled fire on scene and another bls company transported the pt, with vitals under systolic bp of 50/30. She didnt make it to the hospital alive. I reported the facility to DHS and the EMS agency, and I was fired for depriving her of ALS care, by not transporting. No regrets, other than not putting on my gurney and waiting for fire out front.:sad:


Once I've been given report, and I've made patient contact, that patient is under my care. Patient Care has been legally transferred to me at that point. If the facility refuses to call 911, I will and while waiting for them to arrive, I'd package the patient for transport and put the patient in my ambulance for transport if needed. If my ambulance is fully ALS equipped, I'll ask the responding medics to hop in and then I give them report and their evaluation begins. Otherwise, I'll advise the medic to bring their kit and we'll go from there because this patient needs to be transported right _now._ 

If the facility is close enough, I'll initiate transport myself. 

Sometimes you simply must remove the patient from the environment and call from your ambulance. I've done that too. 

If the facility is not being helpful, I'll treat the SNF->ED "IFT" as a scene call and go from there. They don't like it when I do that...

Remember, some facilities will refuse to call 911 and use a BLS provider because in their logs it will be recorded as a non-emergent transfer out, which looks more routine than a 911 call. Those facilities probably also do not want any extra scrutiny brought upon themselves for other reasons. 

Every time I come across one of those patients that should have been transported by 911, I'll ask the RN about why they didn't and that does get documented in my report and is relayed during verbal report. 

One call that sticks out is the crushing sub-sternal chest pain, radiating to the left arm and jaw, with "stable vitals" that got transported C3 to the nearest ED by BLS. In the chart, this pt's vitals usually were something like this: BP 124/78 P 84 R 16, pink/warm/dry and I saw this: BP 98/60 P 48 R 28 pale/cool/diaphoretic... anyone see something wrong with this, especially in the setting of CP? Yeah, they refused 911 because the vital signs were stable when they last checked 2 hours prior, (before the chest pain started) and I know this because I asked them. 

And yes, ALS first response would have taken longer than the transport time.


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## CAOX3 (Sep 6, 2011)

California is officially the worst EMS system in the country.  

First explain to me how refusing to transport a patient doesn't constitute negligence.  

And then explain to me what you think a paramedic is going to do for a patient with a low H and H and a pressure in the toilet, if they cant hang blood that patient is going to die just as quick in their truck as yours and arguably faster considering the medic is probably going to grab for a 14 ga and start pumping fluid in to this poor soul chasing some pressure that's unobtainable and causing this fella to just bleed out quicker into his gut.

Take them to the hospital, at least be the one with some common sense in that  god forsaken state.


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## DESERTDOC (Sep 6, 2011)

Well, momoftwins04, you came here seeking advice, and so far have not won me over with your magnetic personality.  While you may be right, in-so-far as LEMSA policy goes,  I would bet that based on what I have seen posted by you so far, there is more to the story and this is not the only incident.

Your condescension has grown old already.


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## the_negro_puppy (Sep 6, 2011)

Mammaoftwins04 said:


> Must be nice to know everything at 26. Youngster.



He might be 26 but at least he has a job. You should have transported the patient upon learning no ALS was available. That was in the best interests of the patient. Instead you decided to stay on scene not wanting to break company policy or guidelines. You were fired anyway and the patient died.


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## JPINFV (Sep 6, 2011)

the_negro_puppy said:


> He might be 26 but at least he has a job.


To be fair, I'm a second year medical student.


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## truetiger (Sep 6, 2011)

This is a good example of the patient being wronged by everyone:
1) The OP for not being a patient advocate
2) The RN for not calling ALS to begin with and canceling ALS.
3) The fire/medics for not making contact with the EMS crew that called them.

Don't be afraid to step on some toes to do right by your patient.


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## epipusher (Sep 6, 2011)

the_negro_puppy said:


> He might be 26 but at least he has a job.



Excellent fellowship.


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## the_negro_puppy (Sep 6, 2011)

epipusher said:


> Excellent fellowship.



I have no sympathy. This person lost their job for being a poor patient advocate, not using common sense and blaming everyone else for them sitting at scene instead of transporting the 12 minutes to hospital, which may have changed the outcome for the patient. They then come on here complaining and flaming when they don't get the sympathy they seek.


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## JPINFV (Sep 6, 2011)

the_negro_puppy said:


> They then come on here complaining and flaming when they don't get the sympathy they seek.



I have a little sympathy. When EMS programs, especially EMT courses, start teaching their students to THINK instead of mindlessly following orders and when EMS IFT companies start actually ensuring their providers understand their system policies instead of stupid rules like "5 minutes" then I'll lose all sympathy. Until then, it's just a reminder of how far EMS has to actually begin acting like a profession instead of acting like the kid who is upset that his older brother can stay up later and walk to the store alone.


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## jjesusfreak01 (Sep 6, 2011)

Hmm, this is a weird situation that I don't think applies in my county. I work IFT, and I would never ever ever transport a patient that unstable (excepting a transport to hospice care with DNR in hand). I would walk in, say this patient needs ALS level care, and call for paramedics. 

If the patient codes, a nursing home is better than the back of a BLS ambulance, even if the nurses are incompetent. Around here, the medics aren't afraid to play onscene, but will transport quick if they know that the patient needs ER level care. Were I working a BLS level EMS ambulance, I would go by my protocols, because that's the only thing that will save my butt and my certification when something goes south. If my medical director says to transport, i'm happy to do so because they have the experience to make those decisions. An LPN working at a nursing home, not so much. 

If a facility refused to allow ALS to be called and instead called for another BLS ambulance, then that facility should be entirely responsible for whatever happens to the patient, up to negligent homicide.


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## truetiger (Sep 6, 2011)

You wouldn't transport an unstable patient if ALS had an extended ETA?


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## JPINFV (Sep 6, 2011)

truetiger said:


> You wouldn't transport an unstable patient if ALS had an extended ETA?




"Your honor, sure the patient died, paramedics were 15 minutes away, and the closest emergency department was 5 minutes away, but the patient didn't die in my ambulance, so I fail to see the issue here."


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## bigdogems (Sep 6, 2011)

jjesusfreak01 said:


> If a facility refused to allow ALS to be called and instead called for another BLS ambulance, then that facility should be entirely responsible for whatever happens to the patient, up to negligent homicide.



Wouldnt happen. Not saying the nursing home was right by any means. But Their defense will be they called an ambulance to have the pt transported. Plus the second BLS private ambulance took the pt without an issue. Plus knowing what the pts problem was there would be nothing for ALS to do. Sure they can give a fluid bolus but it still doesn't have oxygen carrying ability.


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## bigdogems (Sep 6, 2011)

JPINFV said:


> "Your honor, sure the patient died, paramedics were 15 minutes away, and the closest emergency department was 5 minutes away, but the patient didn't die in my ambulance, so I fail to see the issue here."



:rofl:


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## Handsome Robb (Sep 6, 2011)

What happened to not delaying transport? Even if you get an ALS shortly after starting transport the pt is that much closer to definitive care AND has ALS...


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## Sasha (Sep 6, 2011)

Mammaoftwins04 said:


> My company policy on ALS calls is to load and go if the facility is within 5 mins. However, it contradicts L.A. County scope of practice. I recently was on a call for a Low H and H to the E.R. on a Sunday, from a SNF. The patient was clearly an ALS call and there was no ER within 5 mins. I refused to transport, her v/s were BP-64/40, Cool clammy and diaphoretic, A/O- o, and tachy. This patient is a regular of mine and she is normally BP systolic 160-180 A/O 4 and able bodied. The facility refused to call als, ofcourse and I called fire. The facility staff R.n. canceled fire on scene and another bls company transported the pt, with vitals under systolic bp of 50/30. She didnt make it to the hospital alive. I reported the facility to DHS and the EMS agency, and I was fired for depriving her of ALS care, by not transporting. No regrets, other than not putting on my gurney and waiting for fire out front.:sad:



Your regret should be that you didn't take the patient to the hospital yourself. So what if it's ALS? What is ALS going to do? Fluids.. sounds more like she needed blood and a hospital over ALS transport.


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## looker (Sep 7, 2011)

There seem to be couple of issue going on here. 

1) Yes it's LA County policy to call 911 if once you arrive on scene patient is obviously ALS and not BLS. 

2) While it was ALS call you clearly did not give IMHO best care possible to PT by refusing to transport. What should have been done is request 911 send either intercept if one was going to get to you before you got to ER or just go to ER l &s. 

3) I looked through your other reply but could not tell if you stayed with patient till another unit arrived. If you left it might be considered abandonment being this patient clearly need transport to ER.

4) At the end of the day it's all about what is in the best interest of the patient. It's likely that if you transported right away PT would been alive when you got to hospital. 

5)  EMS agency likely can't do anything to this facility. DHS will not do anything either as it was staff call on what what is appropriate. 


Judgement is just done from you posted none of us can really say if you were wrong or not being we were not there.


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## Tigger (Sep 7, 2011)

Welcome to working BLS. Sometimes the patient needs to go to the hospital right now. Yeah, it sucks to not get ALS right off the bat for truly sick patients, and I really hate being unable to do about anything during transport for a clearly in-pain, dehydrated, probable UTI patient. But if the ER is 10 minutes away it just does not make since to wait for ALS. All things being equal, I'd rather have the "ALS intervention" done in a hospital than the medic's truck since at least one of the goals of all providers is to get truly sick patients to definitive care.


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## firecoins (Sep 7, 2011)

I am not from California and do not know LA county or Orange county protocol.  

That being said, there are 2 things I learned working at a private IFT company doing BLS responding to nursing home emergencies.

1. Do not fight the RNs at the SNF.  Your company will listen to them over you because they do not want to lose the contract.  The RNs don't know what you need and don't care. Your supervisors just want to please the facility. *YOUR RESPONSIBLE *for patient care.  

2. Remove the nurses from the SNF from the equation. The best thing you can do is transport the patient. Call ALS on your own if needed and go meet them outside of the facility. Take the unstable patient in BLS if you need to.  Do not depend on the nurses to what you think is the right thing to do.  Your only "driver" as far as they are concerned and your taking the patient off their hands. So do that. Take the patient off their hands and do what needs to be done. If you need to divert, do so and write up an incidnet report in addition to the PCR to explain to your company that the patient was crashing. You protected the company from a lawsuit.


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## Bullets (Sep 7, 2011)

this perfectly illustrates what i have seen to be a common problem amongst the IFT EMT's in my area. Many do not work or volunteer for a 911 agency, and have no experience dealing with any form of emergency or critical patient. They deal with simple, stable transports that rarely have issues. They have no experience dealing with ALS availability, LTCF staff in emergent situations, ect.

Its not the EMT's fault for not knowing a better mode of action, its just a experience issue. I was working for my twp and was called to a dialysis center for chest pains. We arrive and while we are assessing a IFT crew is dealing with a patient who is supposed to go home, but is clearly circling the drain, hypovolemic, cyanotic, diaphoretic, all the good stuff. The IFT didnt know what to do. We requested a 2nd Twp truck, split the medic crew and took both.

The IFT supervisor met us at the hospital complaining that we "stole" his patient, thankfully our OLMC doc was there and st him in his place. our docs attitude is as long as you act in the best interest of the patient, you woill do ok, and he will back you up.


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## Hunter (Sep 7, 2011)

all I can say to this is... if you really wanted the patient to get ALS for the patients sake and not for oyur own, Randevous with the ALS would have no only saved the patient time, but it would've saved the you all the hassle, I would've documented that the patient was unstable to begin with, I also work IFT for a privite company and I probably would've called my supervisor just to cover my ***... you know if that was my primary concern.


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## looker (Sep 7, 2011)

Bullets said:


> this perfectly illustrates what i have seen to be a common problem amongst the IFT EMT's in my area. Many do not work or volunteer for a 911 agency, and have no experience dealing with any form of emergency or critical patient. They deal with simple, stable transports that rarely have issues. They have no experience dealing with ALS availability, LTCF staff in emergent situations, ect.
> 
> Its not the EMT's fault for not knowing a better mode of action, its just a experience issue. I was working for my twp and was called to a dialysis center for chest pains. We arrive and while we are assessing a IFT crew is dealing with a patient who is supposed to go home, but is clearly circling the drain, hypovolemic, cyanotic, diaphoretic, all the good stuff. The IFT didnt know what to do. We requested a 2nd Twp truck, split the medic crew and took both.
> 
> The IFT supervisor met us at the hospital complaining that we "stole" his patient, thankfully our OLMC doc was there and st him in his place. our docs attitude is as long as you act in the best interest of the patient, you woill do ok, and he will back you up.



I would not blame emt for not knowing what to do but instead emt not following protocol fully. OP should have called 911 and request als intercept. If one wasn't closer compare to l &s to neared ER he should go straight to ER. Refusing to transport delayed pt care and as result pt died.


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## jjesusfreak01 (Sep 7, 2011)

In case I wasn't clear, I wouldn't take this call riding a BLS IFT truck, but I would take it riding a BLS EMS truck, if protocol allowed. 

I would consider this abandonment for the nursing home to try to hand this off to an IFT crew rather than calling for an EMS crew. Maybe my opinion is slightly skewed by the fact that my (EMS) medical director would flip out if he found a BLS IFT truck trying to transport a critical patient to the ER.


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## JPINFV (Sep 7, 2011)

jjesusfreak01 said:


> In case I wasn't clear, I wouldn't take this call riding a BLS IFT truck, but I would take it riding a BLS EMS truck, if protocol allowed.


1. Why would that matter?

2. So you'd delay transporting for someone else to arrive that has the same scope of practice as you do because the name on the truck is different?



> Maybe my opinion is slightly skewed by the fact that my (EMS) medical director would flip out if he found a BLS IFT truck trying to transport a critical patient to the ER.


If your medical director would rather have a BLS IFT crew wait longer for a 911 service than it would take to transport he is, frankly, an idiot. The key is prompt access to a higher level of care. A crew standing around with their collective thumbs up their butt when it would be quicker to take the patient to a higher level of care is definitely not an appropriate response.


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## Sasha (Sep 7, 2011)

jjesusfreak01 said:


> In case I wasn't clear, I wouldn't take this call riding a BLS IFT truck, but I would take it riding a BLS EMS truck, if protocol allowed.
> 
> I would consider this abandonment for the nursing home to try to hand this off to an IFT crew rather than calling for an EMS crew. Maybe my opinion is slightly skewed by the fact that my (EMS) medical director would flip out if he found a BLS IFT truck trying to transport a critical patient to the ER.



IFT ambulances are stocked like 911 ambulances by EMTs and Medics who have gone through the same schooling.

Sent from LuLu using Tapatalk


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## jjesusfreak01 (Sep 7, 2011)

Sasha said:


> IFT ambulances are stocked like 911 ambulances by EMTs and Medics who have gone through the same schooling.



I wish. Our IFT ambulances have no drugs and no advanced airways. I can't fix hypoglycemia, opiate overdoses, give nitro or even aspirin for a chest pain patient. I can't act anywhere near my actual scope. They keep the pulseox in a sealed bag. On an EMS ambulance, I have every drug in my scope (can give them all under standing orders) and access to airway equipment up to BIADs.

Also, I don't trust EMTs who aren't field trained. We shouldn't even pretend that an IFT EMT and an EMS EMT are anywhere near as useful in a real emergency. 

I'm all for getting the patient to the highest level of care as quickly as possible, but considering a situation where EMS (EMT or paramedic level) and IFT are both readily available, a nursing home that calls for a BLS IFT truck for a real emergency should be quickly shut down. My county medical director doesn't provide medical direction to all the IFT companies here (IFTs can choose medical direction from one of the counties they operate in), but the county does have to give them authorization to operate, and I can easily see them shutting down an SNF for this. 

Maybe i'm greatly overestimating the level of medical care that SNF nurses can give in emergency situations. My current thinking is that they have the ability to do IVs for volume replacement and advanced airway therapies. If i'm mistaken on this and in fact a facility nurse is no more useful in an emergency than an EMT-B, then my opinion on this issue may change. My main opposition to BLS crews taking these critical patients is that from an outside standpoint it appears that the SNFs are turfing patients to providers that cannot manage their emergent conditions as well. 

If a nurse can give more advanced care onscene, then it would seem prudent to leave the patient onscene until an ALS transport team arrived. If this isn't the case, then i'd probably just load and go.


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## Sasha (Sep 7, 2011)

How does your company get away with that? All the ambulances here are stocked the same, minus some extrication equipment. We have to meet the same requirements 911 trucks do. 

News flash, nursing homes RARELY call 911. Many IFT EMTs and Medics regularly handle medical and even traumatic emergencies. Not car crashes (obviously) but bad slip and falls, MIs, CHF, psych and diabetic emergencies... Etc. 

I'd be much more comfortable with an IFT EMT/Medic taking a patient they are probably more familiar with to the ER over a 911 medic who has never seen them before.


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## Sasha (Sep 7, 2011)

And yeah, SNFs do have IV abilities, but they one) have to get a doctor's order and two) have to actually get the IV. 

We were called to a hypotensive patient once, BP was below 60 systolic, nurse tried several times to get an IV after dr called her back an hour later to administer fluids. And did I mention I'm IFT?


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## 18G (Sep 8, 2011)

Our IFT trucks are state licensed the same as 911 trucks. No difference. In fact ours are a little better equipped since we have an IV pump and are dual state certified which equals more mobility and drugs. 

POINT#1
As far as the scenario... why in the heck would you ever refuse to transport a critical patient!? I'm failing to see the thinking here. Even if your unit is BLS only the better alternative is to leave them where they are for even longer? As least by transporting you are getting the patient closer to where they need to be. 

POINT#2
If you did your job by recognizing a critical patient and called ALS and someone else impeded their arrival and care of the patient, than that is not your problem. You did your job. Transport the patient and follow-up afterwards. 

POINT#3
FD ALS was cancelled onscene? How does that happen? If a Paramedic makes contact with an ALS patient nobody can cancel them except the patient themselves (not getting into minors/parents and all that). 

POINT#4
Did this patient have a DNR? If so, than why not just transport and avoid this all together?  

POINT#5
For future reference... DO NOT EVER ARGUE AND FIGHT WITH NURSING STAFF. Treat your patient and get the patient into your unit! Your unit is your domain and they have no say. If you would have quickly loaded the patient, you could have called ALS, waited onscene, met enroute, or whatever you felt was best.  
-------

This was a hard lesson to learn since you lost your job but honestly, you did not make the right decision by refusing to transport. This wasn't about you or the nursing staff. It was about the patient and ultimately getting them to a place that can treat them. 

Sure, ALS could have treated the patient depending on what was wrong. Heck, you didn't even know for sure what was wrong. A low H&H? How low? How long has it been low? This pt. could have been hypotensive for a reason totally unrelated to the reported low H&H. ALS care could have made a big difference or honestly no difference at all. If hypotensive from bleeding they were well behind the 8-ball anyway.  

Rapid transport was probably the best treatment.


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## jjesusfreak01 (Sep 8, 2011)

Sasha said:


> How does your company get away with that? All the ambulances here are stocked the same, minus some extrication equipment. We have to meet the same requirements 911 trucks do.



The equipment levels in NC go IFT->EMT->EMT-I->Medic, so the IFT trucks are not similarly outfitted.


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## firecoins (Sep 8, 2011)

Doing IFT, I encountered many legit medical emergencies. We took them to the hospital BLS in many cases. We were flagged down for emergencies as well. And we did do back up 911 for some communitie. 


---
I am here: http://maps.google.com/maps?ll=41.060771,-73.861665


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## JPINFV (Sep 8, 2011)

jjesusfreak01 said:


> I wish. Our IFT ambulances have no drugs and no advanced airways. I can't fix hypoglycemia, opiate overdoses, give nitro or even aspirin for a chest pain patient. I can't act anywhere near my actual scope. They keep the pulseox in a sealed bag. On an EMS ambulance, I have every drug in my scope (can give them all under standing orders) and access to airway equipment up to BIADs.



Are you working in the role of an EMT or EMT-I? The level of the ambulance is just as important as the levels of the providers who staff it. 



> Also, I don't trust EMTs who aren't field trained. We shouldn't even pretend that an IFT EMT and an EMS EMT are anywhere near as useful in a real emergency.


EMTs who don't have field training is a disgrace. However just because an EMT works for an IFT company doesn't mean that they automatically receive no field training nor regularly respond to emergency calls of varying frequency. In fact, I know of at least one screwed up area where the IFT EMTs are more likely better at handling emergent medical patients alone than the 911 EMTs. 



> Maybe i'm greatly overestimating the level of medical care that SNF nurses can give in emergency situations. My current thinking is that they have the ability to do IVs for volume replacement and advanced airway therapies. If i'm mistaken on this and in fact a facility nurse is no more useful in an emergency than an EMT-B, then my opinion on this issue may change. My main opposition to BLS crews taking these critical patients is that from an outside standpoint it appears that the SNFs are turfing patients to providers that cannot manage their emergent conditions as well.


I'm willing to bet big money that SNF nurses can't use advance airways, and will give my first born to bet that they can't RSI. Sure, they can give IV fluids, but I'm not going to bet on them having some sort of grand realization after calling an IFT crew that it's needed. So, sure, they can, but that doesn't mean it's either indicated or that they would do it if it was.


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## JPINFV (Sep 8, 2011)

jjesusfreak01 said:


> The equipment levels in NC go IFT->EMT->EMT-I->Medic, so the IFT trucks are not similarly outfitted.



That's more screwed up than the original situation. An EMT level ambulance should have the same minimum standard regardless of if it's a 911 ambulance or an IFT ambulance.


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