# Ethics Question: BLS Turfing



## RocketMedic (Jan 11, 2014)

Is it ethical to leave a patient in pain or nauseated or who could otherwise benefit from paramedic-level interventions to be attended and treated to a subordinate scope of practice due to a lack of life-threatening need?

Is it right to have EMT-Basics or Intermediates attend patients who could benefit from paramedic-level interventions like pain management, antiemetics or IV fluid?


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## DesertMedic66 (Jan 11, 2014)

IMO no. Pain management is one of the very few things that can make a huge impact on patient care and patient comfort.


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## 46Young (Jan 11, 2014)

The patient that is nauseated and/or in pain should be treated by a paramedic, every time, if they request pharmacological intervention, after being offered these interventions.

Having said that, in a tiered system, sick calls, MVA's, falls, and injuries should be dispatched BLS only. If the BLS onscene determine the need for pain management or anti-emetics, and the patient agrees to/requests these meds, then a request for ALS is indicated. 

What I find inappropriate is when BLS request ALS to get out of a transport, reasoning that the patient may possibly need meds at some point. This need should be confirmed prior to requesting ALS. Offer the meds to the patient and get their consent, or otherwise it should be an obvious case where the patient cannot be moved without significant pain.

Really, in any "all-ALS" system, the situations where we can make a real difference is in the area of pain management and comfort care. Anyone who has done this for more than a minute knows that most of the calls in an all-ALS system are typically V.O.M.I.T calls - Vitals, Oxygen, Monitor, IV, Transport. Medics that willingly withhold pain management whenever possible are barbaric, and probably lazy, since they don't want to be hassled with restock procedures, and mandatory PCR QA/QI for narcotics usage (in some systems).


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## medicsb (Jan 12, 2014)

In a system with limited resources, tying up ALS for anti-emetics or pain management may not be possible for every person that is puking or in pain.  Up to a point, the nauseous and the "in pain" need to "walk it off".  It's silly to go handing out fentanyl or morphine to everyone who says they're in pain (or asks for "something" for the pain).  But, I agree, it can be quite cruel to not treat when you have the means.  Where does one draw the line?  I'm not really sure, but I know it needs to be drawn.

Again, we're talking about setting where ALS is a limited resource (e.g. the county of 950K with 11 medic units at peak hours).  In such circumstances, I'd rather ALS be available for chest pains, respiratory emergencies, unconscious patients, etc.  However, this is not to say that ALS for pain management only should never be done, just that one should be conservative to a certain extent.

Ultimately, I don't see any reason why an AEMT/EMT-I should not be allowed to give zofran ODT, motrin, or even IN fentanyl.


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## triemal04 (Jan 12, 2014)

46Young said:


> The patient that is nauseated and/or in pain should be treated by a paramedic, every time, *if they request pharmacological intervention,* after being offered these interventions.


No.  In fact, absolutely not.  You don't give people medications because they ask for them, you give them because there is a need for them.  If there is no need for them, then no offer of their administration should be made.


46Young said:


> Really, in any "all-ALS" system, the situations where we can make a real difference is in the area of pain management and comfort care. Anyone who has done this for more than a minute knows that most of the calls in an all-ALS system are typically V.O.M.I.T calls - Vitals, Oxygen, Monitor, IV, Transport. Medics that willingly withhold pain management whenever possible are barbaric, and probably lazy, since they don't want to be hassled with restock procedures, and mandatory PCR QA/QI for narcotics usage (in some systems).


If you (general "you") work in an all ALS system and the patient has a "need," even if it is very minimal need, for something you can do then absolutely, do your job and treat them.  That shouldn't take a lot of thinking about.

If on the other hand, you work for a truly tiered system with minimal ALS units and a lot of BLS units, you will have to make the decision about what that patient actually needs right then, versus what they can wait 20-60 minutes for, and what impact, if any, you will have on their current illness, overall mortality, potential length of hospital stay, potential ICU admission.  You'll have to base the comfort needs of the patient against the limited resources that are available for more emergent needs.

Then there's people who run in combined ALS/BLS units.  Maybe a little bit of a tougher decision; do you make the paramedic take everything because there is some small thing they can do to make the patient more comfortable (even if they weren't that uncomfortable), or do you make the EMT do their job and treat patient's that don't have an immediate need for medications?

We have the ability to give a lot of medications and treat a lot of different things; this needs to be tempered with the understanding that just because we can, doesn't mean that we always need to, or should.


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## Rialaigh (Jan 12, 2014)

You asked if it is ethical to withhold from those that are not in "life threatening need". I say no it is not ethical. However I think it is perfectly ethical to withhold from those not having an "emergency"

From an ethics standpoint it is absolutely okay to withhold ALL treatment from patients that have been determined to not have an *emergency situation*. This includes transport. From a legal standpoint obviously things are quite different. 

I define an emergency situation as something that will not resolve without medical intervention and could worsen greatly within 48 hours or leave permanent disability.


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## sir.shocksalot (Jan 12, 2014)

At what point do people take the pt's subjective experience into account? Pain, nausea, and discomfort are subjective experiences that may or may not have objective findings. At what point can anyone ethically say that someone is not in pain or that their pain is not sufficient enough to warrant treatment?

I understand that system abusers exist and providing them with treatments and services that they abuse negatively affects those that might need those services. Does anyone have systems in place to track and warn providers when they are running on a system abuser or drug seeker? If not, do you simply rely on your gut? If so, how many people have gone without treatment because their behavior made you believe they were seeking?

The only ethical thing to do is to assume that anyone who has called with a complaint warrants treatment. If an antiemetic or analgesic is indicated then it should be offered. If the patient doesn't want the medication then no, a paramedic doesn't need to attend provided no other ALS treatment is indicated. I'd rather treat 100 seekers than miss one person who is legitimately in pain or discomfort. If that means I'm stuck attending on every patient... Well, at least I'm earning the $8 extra an hour over my EMT.


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## Rialaigh (Jan 12, 2014)

sir.shocksalot said:


> At what point do people take the pt's subjective experience into account? Pain, nausea, and discomfort are subjective experiences that may or may not have objective findings. At what point can anyone ethically say that someone is not in pain or that their pain is not sufficient enough to warrant treatment?
> 
> I understand that system abusers exist and providing them with treatments and services that they abuse negatively affects those that might need those services. Does anyone have systems in place to track and warn providers when they are running on a system abuser or drug seeker? If not, do you simply rely on your gut? *If so, how many people have gone without treatment because their behavior made you believe they were seeking?*
> 
> The only ethical thing to do is to assume that anyone who has called with a complaint warrants treatment. If an antiemetic or analgesic is indicated then it should be offered. If the patient doesn't want the medication then no, a paramedic doesn't need to attend provided no other ALS treatment is indicated.* I'd rather treat 100 seekers than miss one person who is legitimately in pain or discomfort.* If that means I'm stuck attending on every patient... Well, at least I'm earning the $8 extra an hour over my EMT.


To comment on your bold statement, I have never withheld LIFE OR LIMB SAVING TREATMENT. I don't think it's fair to group all treatments we have available to us into the same group. I am surely not going to judge you for not medicating a patient that was having legitimate pain. Frankly if we operate under an "emergency medical service" mindset it's not our role. 


When is the cost to high for you? 1000 seekers to one legit person? A million? it is absurd to have an all or nothing attitude about treating patients like this. 

It depends on what is causing the pain for me, not as much how much pain you are in although that will still factor some.


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## Carlos Danger (Jan 12, 2014)

medicsb said:


> *In a system with limited resources,* tying up ALS for anti-emetics or pain management may not be possible for every person that is puking or in pain.  Up to a point, the nauseous and the "in pain" need to "walk it off".  It's silly to go handing out fentanyl or morphine to everyone who says they're in pain (or asks for "something" for the pain).  But, I agree, it can be quite cruel to not treat when you have the means.  Where does one draw the line?  I'm not really sure, but I know it needs to be drawn.
> 
> Again, we're talking about setting where ALS is a limited resource (e.g. the county of 950K with 11 medic units at peak hours).  In such circumstances, I'd rather ALS be available for chest pains, respiratory emergencies, unconscious patients, etc.  However, this is not to say that ALS for pain management only should never be done, just that one should be conservative to a certain extent.
> 
> Ultimately, I don't see any reason why an AEMT/EMT-I should not be allowed to give zofran ODT, motrin, or even IN fentanyl.



This.


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## jrm818 (Jan 12, 2014)

Rialaigh said:


> To comment on your bold statement, I have never withheld LIFE OR LIMB SAVING TREATMENT. I don't think it's fair to group all treatments we have available to us into the same group. I am surely not going to judge you for not medicating a patient that was having legitimate pain. Frankly if we operate under an "emergency medical service" mindset it's not our role.
> 
> 
> When is the cost to high for you? 1000 seekers to one legit person? A million? it is absurd to have an all or nothing attitude about treating patients like this.
> ...



While I think we can all understand the thought to restrict EMS to purely life or limb threatening problems, the role  of EMS seems to have morphed in the current system.  truly life threatening problems don't seem to be a very large percentage of EMS call volume and, frankly, EMS treatment is impotent when confronted with many life-threatening problems and basic transport is probably most important).  Similarly, it is extremely difficult to determine a priori what conditions have the possibility to deteriorate and constitute emergencies...the data that I am aware of actually suggest that emergency department mis-utilization isn't as big a problem as we think, and this may be true of EMS as well.

Medical attitudes to treating pain have shifted somewhat (or gone back to basics: treating pain has always been a huge part of medicine, including emergency care), and its a place that EMS has a chance to demonstrate its added value to patients.  Many EMS providers would be out of jobs were we to truly restrict EMS to life-saving care only (and since transportation to an ED is an adequate treatment even for many life-threatening conditions perhaps paramedics would not be quite as needed in areas near to a hospital. 

While it may be ethical to have a system that refuses to transport patients with non-life threatening conditions, if you are going to transport a patient and thus be unavailable for other calls anyways, what justification is there for refusing to manage your patients complaint to the best of your ability, including their complaint of pain?  Are we too good for them?


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## DrankTheKoolaid (Jan 13, 2014)

triemal04 said:


> No.  In fact, absolutely not.  You don't give people medications because they ask for them, you give them because there is a need for them.  If there is no need for them, then no offer of their administration should be made.
> 
> 
> 
> ...






In regards to the ALS/BLS crews and the Medic turfing it to their BLS partner.  I'm going to make an assumption here that the company bills like every company I'm aware of in California. Even if the BLS partner takes the patient as long as a Paramedic is on board that patient is being charged the ALS1 level rate. So why would the Parmedic not take the call since the patient is being billed the same either way. 

That I do find unethical.  If the patient is paying for paramedic level care why is it not being provided, even if it is baby sitting.


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## mycrofft (Jan 13, 2014)

Let me see if I got it.

A paramedic is not sent, or refuses to attend a patient, since the call is not "life threatening"? And measures to stop a patient's severe distress are not in the scope of the responder sent?

1. If the Paramedic responds but on arrival refuses to attend despite dispatch and it's up to a paramedic to ameliorate pain and suffering, the paramedic is wrong. Ditto if the paramedic refuses to go at all.

2. If the dispatch was for an EMT instead of a paramedic because the dispatcher thought it didn't require a paramedic, the dispatcher is triaging by phone, which is damned risky and probably the dispatcher is not a qualified medical person anyway. 

3. If it was a triage question where the presence of the (only?) paramedic at your case endangered someone else (a definite case, not "there might be an emergency") by their absence, then they are right.
IMHO.


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## Rialaigh (Jan 13, 2014)

jrm818 said:


> While I think we can all understand the thought to restrict EMS to purely life or limb threatening problems, *the role  of EMS seems to have morphed in the current system.  truly life threatening problems don't seem to be a very large percentage of EMS call volume and, frankly*, EMS treatment is impotent when confronted with many life-threatening problems and basic transport is probably most important).  Similarly, it is extremely difficult to determine a priori what conditions have the possibility to deteriorate and constitute emergencies...the data that I am aware of actually suggest that emergency department mis-utilization isn't as big a problem as we think, and this may be true of EMS as well.
> 
> Medical attitudes to treating pain have shifted somewhat (or gone back to basics: treating pain has always been a huge part of medicine, including emergency care), and its a place that EMS has a chance to demonstrate its added value to patients.  Many EMS providers would be out of jobs were we to truly restrict EMS to life-saving care only (and since transportation to an ED is an adequate treatment even for many life-threatening conditions perhaps paramedics would not be quite as needed in areas near to a hospital.
> 
> While it may be ethical to have a system that refuses to transport patients with non-life threatening conditions, if you are going to transport a patient and thus be unavailable for other calls anyways, what justification is there for refusing to manage your patients complaint to the best of your ability, including their complaint of pain?  Are we too good for them?



The problem is we are responding to a vast majority of non emergency calls while trying to still act like a emergency system. The issue is one that I could write pages on and it filters down to everything from response times to pain management and everything between.

As far as the current system I work in, you have to have online medical control for pain meds, period. The hospital we call has 2-3 physicians on at a time (generally 2) and is a 20 bed main ER that they are responsible for with a 6 bed fast track and then we utilize up to 10 "hallway stretchers) and frequently patient volume is over 50 in the department for 8-12 hours of the day. I am not going to take up a physicians time at this facility for someone with non descript unidentifiable pain with stable vitals that I think will likely end up going to triage (and thus the waiting room) anyway at this ER. 

When protocols are advanced in this state and the system is changed to reflect the nature of the calls we run, AND, we are given more options for pain medication then I will be more than happy to try and medicate everyone who has a complaint of pain.


Quite frankly my pain management options here are morphine, and fent. That is it. If I had some non narcotic options I would be very happy as would the patients.


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## triemal04 (Jan 13, 2014)

DrankTheKoolaid said:


> I'm going to make an assumption here that the company bills like every company I'm aware of in California. Even if the BLS partner takes the patient as long as a Paramedic is on board that patient is being charged the ALS1 level rate. So why would the Parmedic not take the call since the patient is being billed the same either way.
> 
> That I do find unethical.  If the patient is paying for paramedic level care why is it not being provided, even if it is baby sitting.


Maybe that's part of the reason so many places in California have terrible care and are being investigated by the feds; what you just referenced is called insurance fraud.


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## DrankTheKoolaid (Jan 13, 2014)

Actually that is by Medicare rules, well at least that is how it was explained to us by our billing company


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## triemal04 (Jan 13, 2014)

DrankTheKoolaid said:


> Actually that is by Medicare rules, well at least that is how it was explained to us by our billing company


To be an ALS1 rate the paramedic has to at minimum assess the patient and perform an "ALS intervention."  

So yes, technically they could do an assessment, run an ekg, turn the patient over to the EMT and bill it as an ALS1 call.  I think.

But if they did nothing, and just were there, that couldn't be billed as ALS1.


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## DrankTheKoolaid (Jan 13, 2014)

Right. This is strictly 911 I'm talking about and everyone is assessed by the Medic before being given to a BLS partner


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## triemal04 (Jan 13, 2014)

DrankTheKoolaid said:


> Right. This is strictly 911 I'm talking about and everyone is assessed by the Medic before being given to a BLS partner


Not neccasarily.  When I work with an EMT I don't talk with every patient or do something; if it's a call that they may be taking there is no reason that they can't do their own assessment and I'll listen in and decide whether or not to take over.  Even if I ask a couple of questions that would still be insurance fraud.

Good god, no wonder so many EMT's are incompetant; apparently they aren't allowed to assess a patient if that person called 911.   :wacko:


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## DrankTheKoolaid (Jan 13, 2014)

No that's not the case, in the system I'm talking about I always tried to encourage partners to start off every patient contact and give me the signal when I needed to take over. Obviously I'm doing my own assessment while they are doing this also.  And the majority of the paramedics there had the same mindset. We always encourage further education and stepping out of there comfort zones to encourage them


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## NomadicMedic (Jan 13, 2014)

Rialaigh said:


> The problem is we are responding to a vast majority of non emergency calls while trying to still act like a emergency system. The issue is one that I could write pages on and it filters down to everything from response times to pain management and everything between.
> 
> As far as the current system I work in, you have to have online medical control for pain meds, period. The hospital we call has 2-3 physicians on at a time (generally 2) and is a 20 bed main ER that they are responsible for with a 6 bed fast track and then we utilize up to 10 "hallway stretchers) and frequently patient volume is over 50 in the department for 8-12 hours of the day. I am not going to take up a physicians time at this facility for someone with non descript unidentifiable pain with stable vitals that I think will likely end up going to triage (and thus the waiting room) anyway at this ER.
> 
> ...




The fact that you don't want to bother the doc to get orders to medicate a patient that may need it is beyond disturbing. 

Here's a pro tip. BOTHER THE DOC.


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## Serberrus (Jan 13, 2014)

Judgement call, how bad is the pain? Its obviously not life threatening. Is that medic needed elsewhere? Will tying up that medic leave a significant area without rapid ALS coverage? Too many factors for a simple answer.


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## triemal04 (Jan 13, 2014)

DrankTheKoolaid said:


> No that's not the case, in the system I'm talking about I always tried to encourage partners to start off every patient contact and give me the signal when I needed to take over. Obviously I'm doing my own assessment while they are doing this also.  And the majority of the paramedics there had the same mindset. We always encourage further education and stepping out of there comfort zones to encourage them


Ok...that's more as it should be...but not what you said...and in that case, if the EMT remains in charge any billing above the BLS level would be fraudulent.


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## triemal04 (Jan 13, 2014)

Rialaigh said:


> I am not going to take up a physicians time at this facility for someone with non descript unidentifiable pain with stable vitals that I think will likely end up going to triage (and thus the waiting room) anyway at this ER.


I usually agree with you, and have the same sentiments when this topic or similar ones come up...but the above is pretty bad.

It's not fun to have lousy and/or improper protocols that you have to follow, and it's unfortunate that you have to get permission before you can do certain things...but if you are using that as a reason to not treat someone that you otherwise would...that's wrong.

If you have a patient that, if you didn't have to get permission, would be treated with a specific medication, then you really should be doing what is needed to get permission.

Now, if you wouldn't be treating that person regardless of what was required before doing so then all bet's are off.  Maybe that was what you meant in the above quote?


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## Wheel (Jan 13, 2014)

triemal04 said:


> I usually agree with you, and have the same sentiments when this topic or similar ones come up...but the above is pretty bad.
> 
> It's not fun to have lousy and/or improper protocols that you have to follow, and it's unfortunate that you have to get permission before you can do certain things...but if you are using that as a reason to not treat someone that you otherwise would...that's wrong.
> 
> ...



I think this is what he meant.


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## triemal04 (Jan 13, 2014)

Wheel said:


> I think this is what he meant.


Most likely, just wanted to be sure.


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## Rialaigh (Jan 13, 2014)

triemal04 said:


> I usually agree with you, and have the same sentiments when this topic or similar ones come up...but the above is pretty bad.
> 
> *It's not fun to have lousy and/or improper protocols that you have to follow, and it's unfortunate that you have to get permission before you can do certain things...but if you are using that as a reason to not treat someone that you otherwise would...that's wrong.
> 
> ...




If you have a patient that should get morphine because they are hurting, but you can't get an IV, are you going to drill an IO just to give them 4 of morphine for a 20 minute transport...I sure hope not. In the same way I am not going call a physician for a patient that is in pain that has been going on for 2 days, is non descript, I can't find a source for, and I don't need the pain medication to move or transport them. 

The difficulty of the intervention and the amount of time it takes is factored into whether or not it is worth doing for the patient


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## DrankTheKoolaid (Jan 13, 2014)

triemal04 said:


> Ok...that's more as it should be...but not what you said...and in that case, if the EMT remains in charge any billing above the BLS level would be fraudulent.




Sorry I wasn't more clear. lol im on duty and system was going into the crapper and I had to make it brief


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## Rialaigh (Jan 13, 2014)

DEmedic said:


> *The fact that you don't want to bother the doc to get orders to medicate a patient that may need it is beyond disturbing.
> 
> Here's a pro tip. BOTHER THE DOC.*




I medicate patients that NEED the pain medication to be treated, moved, transported, extreme pain that is affecting vitals or breathing..etc... Other medication of patients in pain is not a NEED...it is a luxury just like a blanket to keep them warm or fluids to rehydrate them a bit before the ER.


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## abckidsmom (Jan 13, 2014)

Rialaigh said:


> If you have a patient that should get morphine because they are hurting, but you can't get an IV, are you going to drill an IO just to give them 4 of morphine for a 20 minute transport...I sure hope not. In the same way I am not going call a physician for a patient that is in pain that has been going on for 2 days, is non descript, I can't find a source for, and I don't need the pain medication to move or transport them.
> 
> 
> 
> The difficulty of the intervention and the amount of time it takes is factored into whether or not it is worth doing for the patient




I can usually get access, but this is one of those times that calls for intranasal fentanyl.


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## abckidsmom (Jan 13, 2014)

Rialaigh said:


> I medicate patients that NEED the pain medication to be treated, moved, transported, extreme pain that is affecting vitals or breathing..etc... Other medication of patients in pain is not a NEED...it is a luxury just like a blanket to keep them warm or fluids to rehydrate them a bit before the ER.




Blankets are not a luxury. They are BLS care, and one of the key parts of taking good care of sick people. 


Fluids are often just the first step in making people feel better. 

Are we here to save lives? I would say no. We are here to make people feel better on their worst days. Very rarely do we save lives. Choosing not to take good care of people because it would bother the doc (stupid protocol) or take time restocking is lazy, pure and simple. 

What's the line they have to cross before they NEED pain meds in your mind?


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## NomadicMedic (Jan 13, 2014)

Rialaigh said:


> I medicate patients that NEED the pain medication to be treated, moved, transported, extreme pain that is affecting vitals or breathing..etc... Other medication of patients in pain is not a NEED...it is a luxury just like a blanket to keep them warm or fluids to rehydrate them a bit before the ER.




Pain management is not a luxury.

You might want to stop now before you embarrass yourself further.


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## DrankTheKoolaid (Jan 13, 2014)

DEmedic said:


> Pain management is not a luxury.
> 
> You might want to stop now before you embarrass yourself further.




That


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## mycrofft (Jan 13, 2014)

I'm sorry, I've missed something.

Is there a rule or law or protocol that you can decide whether or not to treat a patient adequately, or at all, based on whether or not the case is exciting enough?

?!​
And as  for billing over what you delivered, simple fraud. 

PS: another debate to spark: "in enough pain"…starting in the late Nineties (remember "Pain is the latest vital sign"?) we got railroaded into giving pain Rx on demand and now we are fighting Rx abuse and addiction. Not that what YOU give on one call is going to addict anyone. And there are non-narcotic drug alternatives for many instances of "discomfort" (pain).


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## Wheel (Jan 13, 2014)

I think there is a misunderstanding going on. I don't think anyone is saying don't treat someone that is truly in pain. The examples given have been pain that has been going on a while, with no apparent source, no change in vitals, no distress, etc. Is everyone here giving patients with non descript abdominal pain x 2 days narcs, when they aren't in distress?

I mean if a patient is in distress, or is having pain affect vitals, has a history of pain that needs to be managed (crohns, kidney stones, sickle cell, etc), or an obvious sign of pain, then absolutely treat it. I'm just wondering if you give pain meds to anyone that says they are in pain, regardless of presentation.


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## Rialaigh (Jan 13, 2014)

Wheel said:


> I think there is a misunderstanding going on. I don't think anyone is saying don't treat someone that is truly in pain.* The examples given have been pain that has been going on a while, with no apparent source, no change in vitals, no distress, etc. Is everyone here giving patients with non descript abdominal pain x 2 days narcs, when they aren't in distress?*
> 
> I mean if a patient is in distress, or is having pain affect vitals, has a history of pain that needs to be managed (crohns, kidney stones, sickle cell, etc), or an obvious sign of pain, then absolutely treat it. I'm just wondering if you give pain meds to anyone that says they are in pain, regardless of presentation.




This, I believe I am being misunderstood to some extent. I have no non narcotic alternatives. And yes, Management of pain that appears to have the patient in NO distress is a luxury. 

If you guys are giving narcs to every patient who SAYS their pain level is a 6/10 or higher then ...welp.....:unsure:


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## Rialaigh (Jan 13, 2014)

just to pose a question do you give benzo's to every single patient who looks anxious and complains of anxiety? because anxiety is a real medical condition...and by what I am being told here we are obligated to treat it to the fullest extent regardless of whether it is an emergency at all or not.


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## abckidsmom (Jan 13, 2014)

Rialaigh said:


> This, I believe I am being misunderstood to some extent. I have no non narcotic alternatives. And yes, Management of pain that appears to have the patient in NO distress is a luxury.
> 
> If you guys are giving narcs to every patient who SAYS their pain level is a 6/10 or higher then ...welp.....:unsure:



So what's the line they need to cross to qualify for non-luxury pain meds in your mind?


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## Carlos Danger (Jan 13, 2014)

abckidsmom said:


> So what's the line they need to cross to qualify for non-luxury pain meds in your mind?



Well obviously, there is some judgment involved there.....


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## Rialaigh (Jan 13, 2014)

abckidsmom said:


> So what's the line they need to cross to qualify for non-luxury pain meds in your mind?



Whats the line that they need to cross to qualify for Adenosine in the field, hr of 150? HR of 160   HR of 170? symptoms make a difference? history make a difference?  does your ability to use cardizem change your decision making on it..is it a patient to patient decision for you? 


I use my assessment as a whole to make the decision on pain medication. I don't look at my protocol book and ask for narcotics for every patient that complains of pain 6/10 or higher (as the protocol book says I CAN do). I don't have alternatives to narcotics, it's all I have. And Narcotics are not appropriate pain management for even all legitimate pain.


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## triemal04 (Jan 13, 2014)

Rialaigh said:


> just to pose a question do you give benzo's to every single patient who looks anxious and complains of anxiety? because anxiety is a real medical condition...and by what I am being told here we are obligated to treat it to the fullest extent regardless of whether it is an emergency at all or not.


Hey hey hey!  Don't try and bring a shred of common sense into the great pain management debate; all that's allowed here is rhetoric, emotion, personal belief, the demand to do something so that we can do something, and treatments based on what happened to the provider.


Rialaigh said:


> If you have a patient that should get morphine because they are hurting, but you can't get an IV, are you going to drill an IO just to give them 4 of morphine for a 20 minute transport...I sure hope not.


Or you just give it IM.  While I understand the point you're making...bad analogy.


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## NomadicMedic (Jan 13, 2014)

A woman with a ruptured ovarian cyst that's been in pain for days ...

A guy with kidney stones...

A kid with sickle cell...

My mom with a fractured hip. 

Which one gets pain management?

...or do you decide not to bother the doc for any of them?


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## triemal04 (Jan 13, 2014)

Halothane said:


> Well obviously, there is some judgment involved there.....


It's not that obvious from reading many of the responses in the dozens (at least it seems like that many) of different threads this has come up in; the continual mantra is "if the patient says they are in pain you have to treat them, and if narcotics are all you have that is perfectly appropriate."

I still can't understand why people here will harp about how people in EMS need to be better educated (we do) and need to be better at assessing patients and making appropriate, non-protocol driven decisions (we do) and then say something as asinine as that.


----------



## Rialaigh (Jan 13, 2014)

DEmedic said:


> A woman with a ruptured ovarian cyst that's been in pain for days ...
> 
> A guy with kidney stones...
> 
> ...



Which ones are identifiable acute events? Your clearly trying to trap me into saying the fractured hip and then tell me why I am wrong for not medicating the other 3....

If the sickle cell patient has been in pain for days its not acute
The ovarian cyst you said days of pain, again not acute.
The kidney stone may have been in pain for days..not acute. 

I do not in any way feel responsible for treating non acute non identifiable pain. Could and would I choose to treat this occasionally. Yes, but don't tell me it's my responsibility legally and ethically as an EMS provider to treat pain in non acute conditions with non descript pain from people that quite frankly know they could have had someone pick them up and take them to the hospital yesterday. Now very symptomatic pain that is causing some detrimental symptoms absolutely treatable.


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## triemal04 (Jan 13, 2014)

DEmedic said:


> A woman with a ruptured ovarian cyst that's been in pain for days ...
> 
> A guy with kidney stones...
> 
> ...


Show me the patient.  I've treated people with each of those problems and not all of them required medications to relieve their pain, either from me, or in the hospital.  Of the ones that did, not all needed more than tylenol or toradol.

And I've had patients who had the above who required narcotics, sometimes in very large doses.

But then...I always like to assess my patients and decide on an appropriate treatement before starting to treat them.


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## NomadicMedic (Jan 13, 2014)

Because you ARE wrong for not medicating the other three. 

I don't know how to make it any clearer. Wait til you have a kidney stone. Wait til you get in a car wreck and fracture your leg. Wait til you are in pain and the paramedic has a bag full if pain meds and decides NOT to give them to you because he doesn't want to bother the doc.

It's not YOUR pain. It's the patients. YOU are not allowed to judge who's worthy and who's not.


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## Rialaigh (Jan 13, 2014)

DEmedic said:


> Because you ARE wrong for not medicating the other three.
> 
> I don't know how to make it any clearer. Wait til you have a kidney stone. Wait til you get in a car wreck and fracture your leg. Wait til you are in pain and the paramedic has a bag full if pain meds and decides NOT to give them to you because he doesn't want to bother the doc.
> 
> It's not YOUR pain. It's the patients. YOU are not allowed to judge who's worthy and who's not.



Then you can't judge who's anxious or not, I demand you give benzos to every patient that complains of anxiety next shift....<_<

Next patient that says their thirsty absolutely has to get a liter of fluid as well...


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## NomadicMedic (Jan 13, 2014)

Rialaigh said:


> Then you can't judge who's anxious or not, I demand you give benzos to every patient that complains of anxiety next shift....<_<




I never made the statement that I withhold medication because I don't want to bother the doc. That was you pal.


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## Rialaigh (Jan 13, 2014)

DEmedic said:


> I never made the statement that I withhold medication because I don't want to bother the doc. That was you pal.





DEmedic said:


> It's not YOUR pain. It's the patients. YOU are not allowed to judge who's worthy and who's not.





That wasn't the point you made in the last several posts, you made the point that who am I to judge pain, and who are you to judge anxiety or dehydration....


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## CentralCalEMT (Jan 13, 2014)

That is one thing I like about my system. If a paramedic is on scene (which is most of the time as we are a rural system so most of the few ambulances we have are ALS) then the paramedic rides in the back with the patient. 

Personally, as a medic, I like this rule because in 2014 we are not just there for life and death emergencies. Being a medic is about more than pushing medications. Sometimes we are the only people who take the time to explain to our patient's how to take care of themselves. There are so many people lacking primary care, or having primary care MDs that are too busy to explain things. For example, the other day, I had a patient with a history of CHF on diuretics. She said she had not been taking them. When I asked why, she said she did not think it was important. I explained what CHF was and why taking medications as prescribed was so important. It was like a light went on in her head and she promised to take better care of herself so she could be there for her grandchildren. Did I do anything remotely ALS on that call besides Monitor/IV? Absolutely not. Was I able to use my knowledge to help someone better themselves? Yes I was. Not that some EMTs can't do the same' but a lot do not have the knowledge base of that disease process and pharmacology to have that discussion with the patient.

I came from the LA county system where fire responds in either an ALS engine or ALS squad and the ambulance is BLS. The fire medic has the choice to turf the patient to BLS and go back to the station. I can't even begin to describe the number of chest pain calls that became "chest wall discomfort" shortness of breath that became "cough and congestion" and altered that became "general weakness" so the paramedic could justify shipping the call BLS. To me that is both unethical and downright wrong. 

Now I understand every system is different and what works for me might not work for someone else in a different system. However, I like the way we do things in my system because I believe it puts the patient first.


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## Wheel (Jan 13, 2014)

DEmedic said:


> A woman with a ruptured ovarian cyst that's been in pain for days ...
> 
> A guy with kidney stones...
> 
> ...



I would say all of them, if the presentation warrants it. Any of them that are in distress will certainly get it. I tend to err on the side of treating the pain, especially in patients with a high pain tolerance (like sickle cell), but physical exam and history will play a part in the decision to medicate a patient, just as with all medications. A blanket statement can't be made about treating pain.


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## NomadicMedic (Jan 13, 2014)

Rialaigh said:


> That wasn't the point you made in the last several posts, you made the point that who am I to judge pain, and who are you to judge anxiety or dehydration....




I don't know if you're being deliberately obtuse because you enjoy an argument... Or you really believe what you're writing. I'm hoping you're not really this guy...



Rialaigh said:


> I don't look at my protocol book and ask for narcotics for every patient that complains of pain 6/10 or higher (as the protocol book says I CAN do).






Rialaigh said:


> ...medication of patients in pain is not a NEED...it is a luxury...



Because if you are, you're a disgrace. 

And with that, I'm done with you.


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## Rialaigh (Jan 13, 2014)

My point about anxiety stands. Anxiety consistently makes almost all serious and non serious conditions worse rapidly. It causes elevated blood pressure, tachycardia, rapid breathing. It can cause people who have an complaint entirely different from anxiety to pass out, become hypoxic or hypercapnic. It exacerbates a variety of conditions that can acutely deteriorate in a short period of time. Yes no one seems to be outraged when we "withold" benzo's from patients complaining of anxiety. 

Why is it that pain management, which by the way pain has many many less of the negative possible side effects than anxiety, is the life or death issue.


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## triemal04 (Jan 13, 2014)

Because to decide if someone needs pain management is to judge them!  And judging someone is baaaaaad!  When you judge someone an angel loses it's wings!  And a baby cries!  And a puppy dies!  And...

Sorry...had to go vomit for a minute.

This ignores the fact that the above is a load of BS, and ignores, yet again, that our job is to assess and examine patient's and treat them in a medically appropriate manner, to the best of our abilities, within the limits imposed by our equipment and surroundings.

To not do that, as would be done by those who advocate treating every complaint of pain without further thought is wrong, and a disgrace.  

End of story.


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## mycrofft (Jan 13, 2014)

Naw, just to protocols.
I keep saying "go to the protocols" because some folks here seem to be bent on finding ways to end-run protocols. Most of the "old heads" seem not to.

I've seen people with serious injuries and no shift in vitals because either they didn't know theory were hurt that bad, they were drunk or high, they were culturally stoic, or they were chronically in pain so it didn't faze them. I got brought to the mat a few times trying to make vitals a definitive sign of pain; they admitted that ACUTE affect (agonal) will tend to match vitals (higher BP/Pulse and sweat) more than longer term issues.

We keep going here to the "life or death issue". EMT's and paramedics have traditionally been trained about life or death issues because their origins are with MVA's and maybe multi casualty events and no further resources. Real medicine, not bandaid and splint techs, includes more than slapping the most on the worst and going the fastest. Cut the drama, most field EMS is not going to be life or death. I hope!!


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## unleashedfury (Jan 13, 2014)

triemal04 said:


> To be an ALS1 rate the paramedic has to at minimum assess the patient and perform an "ALS intervention."
> 
> So yes, technically they could do an assessment, run an ekg, turn the patient over to the EMT and bill it as an ALS1 call.  I think.
> 
> But if they did nothing, and just were there, that couldn't be billed as ALS1.



While this is the way a P/B is supposed to work it rarely works that way, In areas around here where a ALS squad is the primary provider they are dispatched for everything from stubbed toes to cardiac emergencies the ALS provider is supposed to assess the patient and appropriately triage to BLS or continue with ALS assessment and interventions. Is it right that we can legally charge an ALS1 rate for a patient who requires no ALS interventions no do we yep 



Rialaigh said:


> I medicate patients that NEED the pain medication to be treated, moved, transported, extreme pain that is affecting vitals or breathing..etc... Other medication of patients in pain is not a NEED...it is a luxury just like a blanket to keep them warm or fluids to rehydrate them a bit before the ER.



Blankets are not a luxury, its primary care, If we showed up to your house to lets say take your mom to the hospital for weakness and flu like symptoms and throw her on the stretcher strap her in and take her to the hospital no pillow, no blanket just a sheet on the litter, because blankets are a luxury.. would you feel that we provided excellent service?? Probably not. Our job is to assist patients in treating their symptoms, and providing care, sometimes just comfort measures like blankets or positioning is providing care. 



CentralCalEMT said:


> That is one thing I like about my system. If a paramedic is on scene (which is most of the time as we are a rural system so most of the few ambulances we have are ALS) then the paramedic rides in the back with the patient.
> 
> Personally, as a medic, I like this rule because in 2014 we are not just there for life and death emergencies. Being a medic is about more than pushing medications. Sometimes we are the only people who take the time to explain to our patient's how to take care of themselves. There are so many people lacking primary care, or having primary care MDs that are too busy to explain things. For example, the other day, I had a patient with a history of CHF on diuretics. She said she had not been taking them. When I asked why, she said she did not think it was important. I explained what CHF was and why taking medications as prescribed was so important. It was like a light went on in her head and she promised to take better care of herself so she could be there for her grandchildren. Did I do anything remotely ALS on that call besides Monitor/IV? Absolutely not. Was I able to use my knowledge to help someone better themselves? Yes I was. Not that some EMTs can't do the same' but a lot do not have the knowledge base of that disease process and pharmacology to have that discussion with the patient.
> 
> ...


 IMHO if a primary care physician "doesn't care to explain what they are treating their patients for, or tells the patient they don't have time to explain things" Its time to find a new physician. I am sorry its my body, I have the god given right to know whats going on with me, what the medications you are prescribing are going to do for me, and if I don't have a clear understanding as a non medical person, as my Primary care physician you should be more open and helpful, 

To initially respond to the OP's post. most of what you are stating is a judgment call, to withhold interventions from any patient is unethical. But in the same way it comes down to HPI and a solid assessment. why is the patient sick with N/V. are they a cancer patient receiving chemotherapy? are they sick with a viral infection? etc. If N/V is motion sickness related anti-emetics like Zofran are ineffective. Also take in consideration sometimes the closest ALS is a ED. I.E. we provide primary coverage for a town that the hospital is in and 3 minutes away so to have a ALS truck dispatched and enroute to the scene I can have the patient at a higher level of care faster. 

As far as the pain management portion of this thread. This is subjective to the patient. not everyone needs to be pumped full of narcotics to subside their pain. we simply forget that pain management is all or nothing with drugs, there is other interventions first. Often patients can have their pain subside with positioning comfort, and even things like heat or Ice. I've had patients with hip and extremity fractures that had pain relieved by proper positioning for comfort. or simple interventions like ice. and to continue no need to dump the drug box for pain management you can titrate up to the max for pain management depending on your transport time. If a patient pain subsides with 2mg of morphine or 50mcg of fentanyl why should I use the max dosages available to me?


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## ZombieEMT (Jan 14, 2014)

Working in New Jersey, this is a debate that we have frequently at a BLS level. Generally, I do not request an ALS intercept just because of severe pain and/or nausea. I always evaluate the benefit vs loss. If the patient can go with the pain and/or nausea then I will not tie up an ALS unit. If the pain or nausea lead to other life threatening issues or other life treatening issues occur, they will be requested. I might also request ALS for pain, if the pain has become so severe that we can not even move the patient to transport with a yelping scream.


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## ZombieEMT (Jan 14, 2014)

abckidsmom said:


> So what's the line they need to cross to qualify for non-luxury pain meds in your mind?



I think the line is where the need for pain medications turns from comfort care to care for immediate life threats. 

Please do not take this response in the wrong way. I am speaking soley from the system that is ran in New Jersey. While comforting my patient is a priority, I will not request ALS for comfort care. However, if ALS is with us or needed for a seperate issue, treat the pain too.

I see it like this, bandaids are not a requirement for stock on an ambulance in New Jersey. I guess the idea is that people do not call an ambulance for something that just needs a bandaid. However, that does not mean if I go out for a patient who has other injuries or medical complaints requiring an ambulance, that I would not put a bandaid on to treat the minor abrasion/laceration.


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## jgmedic (Jan 14, 2014)

So does any patient that is given a medication then require ALS care during transport, I believe, if your system has competent EMT's they can adequately manage a patient with peripheral access and moderate amounts of pain meds or anti-emetics. My system requires all patients transported by 911 to have a paramedic attendant, which I am more than ok with. I give pain meds and Zofran more than most medics, but barring any other circumstances, I think your typical N/V patient with Zofran given or a patient with non-traumatic pain given MS could be transported BLS if the system allowed, I mean, how many BLS IFT patients are medicated prior to transport anyway?


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## abckidsmom (Jan 14, 2014)

ZombieEMT said:


> I think the line is where the need for pain medications turns from comfort care to care for immediate life threats.
> 
> Please do not take this response in the wrong way. I am speaking soley from the system that is ran in New Jersey. While comforting my patient is a priority, I will not request ALS for comfort care. However, if ALS is with us or needed for a seperate issue, treat the pain too.
> 
> I see it like this, bandaids are not a requirement for stock on an ambulance in New Jersey. I guess the idea is that people do not call an ambulance for something that just needs a bandaid. However, that does not mean if I go out for a patient who has other injuries or medical complaints requiring an ambulance, that I would not put a bandaid on to treat the minor abrasion/laceration.



I guess as a BLS provider you have to bring in to play the risk/benefit analysis of calling ALS, waiting for them to arrive, turning the patient over to them, etc, vs how quickly you can arrive at the hospital by just driving the patient in.  

In my rural system, if I choose not to "comfort" the patient with pain meds or anti-emetics, that sentences the patient (and the providers, BTW) to a looooong ride to the hospital.

I really, really like to get the patient loaded, start on the way to the hospital, give fentanyl and Zofran, tuck the patient in, and have them rest on the way to the hospital.  I HATE listening to someone puke, almost as much as I hate puking myself.  I way prefer getting them comfortable and letting the ride be quiet and uneventful.


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## KingCountyMedic (Jan 15, 2014)

The majority of patients that require ambulance transport are BLS patients. I worked a long, long time in a system that had a paramedic on every rig and you were encouraged to put lines in every one you could. "O2, IV, Monitor every patient you can." This was commonly pushed at staff meetings. Ambulance billing is one of the biggest scams going in my opinion. Where I work now we only transport true ALS patients that need real ALS care and we don't bill for it, it is all tax payer supported. How many patients that get pain and nausea meds that can probably do just fine without them are told before hand that it will likely double their bill and they could possibly get sent to collections for not paying? So in answer to the original questions I would say mostly yes although there's always exceptions.


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## unleashedfury (Jan 15, 2014)

KingCountyMedic said:


> The majority of patients that require ambulance transport are BLS patients. I worked a long, long time in a system that had a paramedic on every rig and you were encouraged to put lines in every one you could. "O2, IV, Monitor every patient you can." This was commonly pushed at staff meetings. Ambulance billing is one of the biggest scams going in my opinion. Where I work now we only transport true ALS patients that need real ALS care and we don't bill for it, it is all tax payer supported. How many patients that get pain and nausea meds that can probably do just fine without them are told before hand that it will likely double their bill and they could possibly get sent to collections for not paying? So in answer to the original questions I would say mostly yes although there's always exceptions.



I'm a firm believer that EMS systems should be a taxpayer system. Afterall in Pa we have the EMS tax which is 52 dollars a year for every working adult. If you get a citation theres a E.M.S. fund that is added to the citation. Where is all this money that the commonwealth gets going to? I don't see any improvements in our current system, we get reimbursements from insurances, memberships and donations. And that's our revenue. 

In response to your reply though, your are quite correct the idea that if your transporting in a ALS rig everyone getting IV O2 Monitor was the norm for a lot of people to get the ALS1 rate, even if they don't need it. I also believe that its not our emergency to decide what interventions should be parlayed most pain can be managed with comfort and BLS skills. and those interventions should take place prior to pharmacological interventions.


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## RocketMedic (Jan 15, 2014)

abckidsmom said:


> Blankets are not a luxury. They are BLS care, and one of the key parts of taking good care of sick people.
> 
> 
> Fluids are often just the first step in making people feel better.
> ...



Amen....and I just got in trouble for this attitude.


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## triemal04 (Jan 15, 2014)

If I had to guess I'd guess the first thing that got you into trouble was your attitude...and not your attitude towards patient care.

If I had to guess I'd guess the second thing that got you into trouble was not treating patient's appropriately.  

The fact that we CAN do something does not mean that we always SHOULD do something.


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## sir.shocksalot (Jan 16, 2014)

triemal04 said:


> If I had to guess I'd guess the first thing that got you into trouble was your attitude...and not your attitude towards patient care.
> 
> 
> 
> ...




Sort of unfair statements to make about someone you don't know, don't you think? Not directed at anyone specifically but we all should be able to have a spirited debate and disagree about approaches to patient care while remaining respectful. IMO at least.

Moving back to the topic at hand. My personal opinion is that not every patient that presents in pain requires narcotics, not all nausea complaints need antiemetics. However, if treatment is indicated it should provided with the patient's best interest in mind. Generalized, vague complaints of mild pain might not need narcotics. That's a discussion that needs to take place with the patient. Pain treatment should be patient centered, if a paramedics decision to treat pain takes into account the patient's race or socioeconomic status they are providing biased care. If a paramedic's decision to treat pain comes down to being too tired, not wanting to ride in to the hospital, not wanting to do any paperwork, not wanting to call in for it, or considers the restock process to be too bothersome they are not putting patient care first.

Put yourself or a loved one in your patient's position. Pain is entirely subjective. The comparison to anxiety is poor. Anxiety can usually be treated adequately by talking and reassurance. I understand the argument and agree that the least invasive treatment should be used first but a lot of pain will need to be medicated. A non-narcotic option would be great but is not an option in my system.

My biggest complaint about tiered systems is that many patients go without proper treatment because they aren't "sick enough" in the subjective opinion of the ALS provider. Although an all-ALS system is not necessarily better either. For tiered systems, pain medications and antiemetics would be great if BLS providers could provide that. I think pain control largely depends on the culture of the EMS agency.

Where I am very adamant is that pain control and patient comfort are fundamental parts of patient care. What that entails is up for debate.


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## RocketMedic (Jan 16, 2014)

Shocksalot, I have the same views and values. My agency apparently does not.


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## Handsome Robb (Jan 16, 2014)

Serberrus said:


> Judgement call, how bad is the pain? Its obviously not life threatening. Is that medic needed elsewhere? Will tying up that medic leave a significant area without rapid ALS coverage? Too many factors for a simple answer.




No there is not. If you're worried about lack of coverage or "should I treat this patients non life threatening complaint appropriately or should I turf it in case something better drops" you need to get into a new line of work.

If your system can't cover itself that's an operations problem. We exist for *the patient*. Otherwise we'd all be out of a job.

Who are you to say who's pain is severe or not? What do you know that the rest of us don't. How'd you like it if I scooped and ran withe your mom and a fractured hip and didn't give her any meds to keep myself available for "something better."

This attitude right here is why I'm going to school to get away from prehospital medicine at the paramedic level.


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## ZombieEMT (Jan 16, 2014)

You are absolutely right, we do exist for the patient. Everyone should be treated at the highest care but life is over comfort. I would rather have the als on patients that require als for life interventions vs for a patient to provide confort care.... why is worrying about coverage an issue? As a ems system there is an obligation to your area not just one patient.  In a perfect system there would be enough als and bls but perfect doesn't exist.


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## usalsfyre (Jan 16, 2014)

unleashedfury said:


> I also believe that its not our emergency to decide what interventions should be parlayed most pain can be managed with comfort and BLS skills. and those interventions should take place prior to pharmacological interventions.


What gives you the right to determine whether it deserves pharmacological intervention or not? Your a medic student. Next time you're doing clinicals pay attention to how many people get pain meds in the ED and leave with a script. You MIGHT learn something.


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## usalsfyre (Jan 16, 2014)

ZombieEMT said:


> You are absolutely right, we do exist for the patient. Everyone should be treated at the highest care but life is over comfort. I would rather have the als on patients that require als for life interventions vs for a patient to provide confort care.... why is worrying about coverage an issue? As a ems system there is an obligation to your area not just one patient.  In a perfect system there would be enough als and bls but perfect doesn't exist.



Sure it does. Every 911 system in my immediate area puts a paramedic on scene 100% of the time. I would venture to say the majority of systems in Texas (and it's a big effing state) do as well. So telling me "there's not enough to go around" is bull crap.


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## usalsfyre (Jan 16, 2014)

KingCountyMedic said:


> The majority of patients that require ambulance transport are BLS patients. I worked a long, long time in a system that had a paramedic on every rig and you were encouraged to put lines in every one you could. "O2, IV, Monitor every patient you can." This was commonly pushed at staff meetings. Ambulance billing is one of the biggest scams going in my opinion.


Or those systems recognized that appropriate assessment and treatment should be starting in the field rather than a taxi ride to the ED 



KingCountyMedic said:


> TWhere I work now we only transport true ALS patients that need real ALS care and we don't bill for it, it is all tax payer supported. How many patients that get pain and nausea meds that can probably do just fine without them are told before hand that it will likely double their bill and they could possibly get sent to collections for not paying? So in answer to the original questions I would say mostly yes although there's always exceptions.



How many patients who are suffering would choose the doubled bill for some relief? I guess we'll never know as long as some systems cling to the outdated belief of paramedics "saving lives".


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## ZombieEMT (Jan 17, 2014)

So Texas is a near perfect state? Even if it is, that only counts for 1 out of 50 states in the wonderful USA. I come from a state that is far from perfect. Here there is not ALS on every call or even almost every call. Both counties that I work in, have two ALS units for the entire county. Many times calls get stacked and no ALS is not available, even when desperately needed. So not requesting ALS for comfort care, is plausible.


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## KingCountyMedic (Jan 17, 2014)

usalsfyre said:


> guess we'll never know as long as some systems cling to the outdated belief of paramedics "saving lives".




Well where I work we do save lives. We save more lives than just about anyplace on the planet! Our system works for us. It's not just Paramedics saving lives, without our dispatch, our public defibs, our citizen CPR and our EMT's we would not be as successful as we are. BUT when someone is dying and needs that tube, needs that line, we will get it. I'd rather have a small group of medics that know how to take care of the truly sick patient than have a ton of medics that never get to intubate, or hardly ever take care of a critical patient, running around to hand out TKO lines and zofran and bill everyone at an ALS rate.


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## STXmedic (Jan 17, 2014)




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## Wheel (Jan 17, 2014)

STXmedic said:


>



Oh no


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## DrParasite (Jan 17, 2014)

ZombieEMT said:


> Here there is not ALS on every call or even almost every call. Both counties that I work in, have two ALS units for the entire county. Many times calls get stacked and no ALS is not available, even when desperately needed.


Let me guess: Hunterdon & Somerset?





KingCountyMedic said:


> BUT when someone is dying and needs that tube, needs that line, we will get it. I'd rather have a small group of medics that know how to take care of the truly sick patient than have a ton of medics that never get to intubate, or hardly ever take care of a critical patient, running around to hand out TKO lines and zofran and bill everyone at an ALS rate.


C'mon, now your introducing evidence based medicine, actual scientific data, and progressive practices.... we can't have that, we need a paramedic on every truck!!!

Our paramedics intubate on average of once a week.  that's per crew, not per agency.  sometimes it's even more.  we are pretty good at it, because we practice it on real patients.

they also only see patient's who need ALS care (well, in theory anyway).  how good of a paramedic can you be when the majorty of the time all you are doing is giving the patient a horizontal ride to the hospital?  if the last time you intubated a real person was 9 months ago, what's going to happen when you look at a difficult airway?

maybe you should do your own research about what really saves lives.  I can guarantee you, the science say it isn't paramedics, despite what you want to believe.


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## Wheel (Jan 17, 2014)

DrParasite said:


> Let me guess: Hunterdon & Somerset?C'mon, now your introducing evidence based medicine, actual scientific data, and progressive practices.... we can't have that, we need a paramedic on every truck!!!
> 
> Our paramedics intubate on average of once a week.  that's per crew, not per agency.  sometimes it's even more.  we are pretty good at it, because we practice it on real patients.
> 
> ...



In his defense he did mention dispatching, public cpr, EMT's, and public aeds as a large part of why his system works so well.


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## DrParasite (Jan 17, 2014)

Wheel said:


> In his defense he did mention dispatching, public cpr, EMT's, and public aeds as a large part of why his system works so well.


actually, that statement was directed at all the people who said you need a paramedic to save lives, and a paramedic on every ambulance or else you are doing your patient's a disservice.  

As screwy as NJ's EMS system is, we utlize our paramedic units in a similar manner to KingCountyMedic's system.  The statement you are quoting wasn't directed at him at all.


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## RocketMedic (Jan 17, 2014)

Gentlemen, I think you misunderstand the question. Systems like KCM1, SoCal FD, and NJ are excellent at specializations like arrest management and "textbook" life-threatening calls because that's what they're designed and built for. The question is not "how do paramedics do when faced with life threats", it's "is it ethical to downgrade or treat a patient to less than the necessary amount to relieve pain and suffering."

Tiered systems are cheaper than non-tiered systems and tend to have more acuity per provider...but they tend to suck at a lot of the non-life-threatening jobs.


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## usalsfyre (Jan 17, 2014)

My question is why can't you provide a paramedic on every call to take care of the "BS comfort stuff" as some people like to call it a d a handful of intercept medics trained to a higher level for those "life-saving" calls. Not all medics have to be high speed low drag...

Of course that might take some humility which seems to be in short supply in many tiered systems.


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## KingCountyMedic (Jan 17, 2014)

RocketMedic said:


> The question is "is it ethical to downgrade or treat a patient to less than the necessary amount to relieve pain and suffering.




Now that I know more of the VH1 behind the scenes story on this particular question (sorry for going off topic Rocket) I would say no, it's not ethical in your particular situation. If you are on an EMT/Paramedic transport rig and you are going to be taking the patient to the hospital regardless of who drives or who rides in back, and they are in pain, nauseated etc. etc. If your protocol or guidelines or whatever you have justify pain control you give it end of story amen.


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## medicsb (Jan 17, 2014)

Considering that the paramedic scope of practice is useless for the majority of calls, why not replace paramedics with AEMTs who can admin fentanyl and zofran?  (There's no reason an AEMT could not.)  And then use paramedics in fly-cars for life-threatening and more acute stuff.  

It's funny, but there seems to be a shift in some circles from "we need more paramedics so we can treat life threatening emergencies quicker" to we need "more paramedics so we can treat all pain and nausea".  

If you want to justify your existence with comfort care, then be willing to give up the meat of your scope of practice.  Sure, comfort care is important (and I'm not saying it should not be done) but it does NOT require the caregiver to be able to intubate, cardiovert, cric, needle decompress, pace, give antiarrhytmics, etc., etc.  Ultimately, pain and nausea does not justify the costs associated with a paramedic's scope of practice.


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## unleashedfury (Jan 17, 2014)

medicsb said:


> Considering that the paramedic scope of practice is useless for the majority of calls, why not replace paramedics with AEMTs who can admin fentanyl and zofran?  (There's no reason an AEMT could not.)  And then use paramedics in fly-cars for life-threatening and more acute stuff.
> 
> It's funny, but there seems to be a shift in some circles from "we need more paramedics so we can treat life threatening emergencies quicker" to we need "more paramedics so we can treat all pain and nausea".
> 
> If you want to justify your existence with comfort care, then be willing to give up the meat of your scope of practice.  Sure, comfort care is important (and I'm not saying it should not be done) but it does NOT require the caregiver to be able to intubate, cardiovert, cric, needle decompress, pace, give antiarrhytmics, etc., etc.  Ultimately, pain and nausea does not justify the costs associated with a paramedic's scope of practice.



Being a Pa Resident you feel my pain, the AEMT scope has been laid out and a foundation set, the local council director quite frankly stated that the AEMT in Pa will probably never be seen in his tenure due to the fact that they been kicking it around for years and no one ever decided to move forward on it. Also more rural squads are fearing the fact of sending volly's to advanced training and associated costs with training.


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## usalsfyre (Jan 17, 2014)

medicsb said:


> If you want to justify your existence with comfort care, then be willing to give up the meat of your scope of practice.  Sure, comfort care is important (and I'm not saying it should not be done) but it does NOT require the caregiver to be able to intubate, cardiovert, cric, needle decompress, pace, give antiarrhytmics, etc., etc.  Ultimately, pain and nausea does not justify the costs associated with a paramedic's scope of practice.




To put forth a REALLY unpopular opinion, the majority of paramedics are vastly under-qualified to do the majority of those things anyway.


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## RocketMedic (Jan 17, 2014)

Total agreement. I think a large part of the avoidance of pain management is a lack of education as to how to safely and effectively do it.

Let's face it, running an AHA ACLS code is easy. Sure, a few tasks might be hard, but the whole thing is easy. Same with CVA and STEMI- take vitals, recognize, slam in nitro and ASA if appropriate and drive fast. There's not too much to worry about there unless things get odd, and then, it's a formulaic, drilled approach.

Managing pain, nausea, and other vague complaints is far more difficult because we're generally not trained for it.


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## abckidsmom (Jan 17, 2014)

RocketMedic said:


> Total agreement. I think a large part of the avoidance of pain management is a lack of education as to how to safely and effectively do it.
> 
> Let's face it, running an AHA ACLS code is easy. Sure, a few tasks might be hard, but the whole thing is easy. Same with CVA and STEMI- take vitals, recognize, slam in nitro and ASA if appropriate and drive fast. There's not too much to worry about there unless things get odd, and then, it's a formulaic, drilled approach.
> 
> Managing pain, nausea, and other vague complaints is far more difficult because we're generally not trained for it.



I agree with usalsfyre, but not so much your "easy" argument.  It's easy to do anything in a mediocre way.  

STEMI?  Meh, if the machine calls it, great, if not, oh well.  I just sat in a class with craigalanevans for 8 hours today.  I'm 20 years into my career, and he gave me at least a months worth of material to process.  My mind is spinning with details that I really didn't know before.

Did I take good care of sick people before?  Yeah, better than most, I'd say with a bit of ego.  Today I learned that there is SO, SO much room for improvement on my game. 

I think that medics get bored with the boring stuff because meh, it's just stuff.  Not exciting, no lives to be saved here, carry on.  

But sniffing out the complicated, non-dramatic, maybe boring issue with your unique perspective of the patient IN THEIR HOME ENVIRONMENT is a thing that really can't be beat.  And if you don't make the patients comfortable and happy, they're going to be too busy taking deep breaths to push down their nausea to really talk to you about what's going on.


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## Brevi (Jan 19, 2014)

Patients with significant pain, those who are nauseated or who are actively vomiting should be cared for, and transported, via ALS when at all possible.


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## RocketMedic (Jan 19, 2014)

Total agreement.


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