# EMS vs EMS



## medic5740 (Dec 12, 2008)

An interesting thing has happened to our EMS agency twice in the last couple of years.  We have to transfer patient care from our EMS agency to another agency in order to get our patient to the hospital.  The issue has come up twice with two different agencies operating in our same medical control service area.  

In both situation, our medical control physician received our report and we received permission to clear c-spine and to forgo spinal motion restriction.  After receiving report from our agency including the report on the physician's orders, these two agencies took responsibility for the patient.  Then they immediately provided spinal motion restriction protection stating that they believed the protocols required it in this situation based upon mechanism of injury even though the patient did not want it done.  They used the scare tactic or "if we don't, you could be paralyzed for life."

What bothers me is the image that this left with the patient about our agency and our providers as well as the audacity of the transfer agency's violation of our medical control physician's orders.  Now, I don't want to bore you with the exact details of these two cases, but doesn't a medical control physician's direct order supercede the protocol?  And weren't these two agencies actually in violation of medical control's physician's orders?


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## BossyCow (Dec 12, 2008)

medic5740 said:


> In both situation, our medical control physician received our report and we received permission to clear c-spine and to forgo spinal motion restriction.  After receiving report from our agency including the report on the physician's orders, these two agencies took responsibility for the patient.  Then they immediately provided spinal motion restriction protection stating that they believed the protocols required it in this situation based upon mechanism of injury even though the patient did not want it done.  They used the scare tactic or "if we don't, you could be paralyzed for life."
> 
> What bothers me is the image that this left with the patient about our agency and our providers as well as the audacity of the transfer agency's violation of our medical control physician's orders.  Now, I don't want to bore you with the exact details of these two cases, but doesn't a medical control physician's direct order supercede the protocol?  And weren't these two agencies actually in violation of medical control's physician's orders?



I would tread very carefully here. The MPD is going to make the call to clear c-spine based on your report to him. If two different agencies have felt the injuries to be more severe than you did, I would be looking long and hard at the incidents before labeling the other agencies nervous nellies.

Does your agency conduct run reviews with the multiple agencies and the MPD? We do and it allows calls like this to be discussed with all parties present. It also brings into the discussion what the ER found upon further exam and the final diagnosis of the pt's injuries. 

At the vey least I would sit with the MPD with the pt record of both instances and find out what he thought after the pt was seen.


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## Ridryder911 (Dec 12, 2008)

I ask why can you not transport the patient? As well, if I am the one transfering I will treat as I see fit, not as you see fit. You called me, not the other way around. Will your physician assume care for me if I am not associated with you? Doubtful. 

The same as if even occurs within a ED or where ever. The moment I assume care, they are my patient and I will treat as appropriate. 

Don't criticize if you cannot fulfill the care. 

R/r 911


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## medic5740 (Dec 12, 2008)

*Further information*

We provide EMS services on an Island thirty plus miles from the mainland hospitals, and although we provide treatment and transport on the island and in the air transport aircraft, we do not have an ambulance at the three airports to which we usually can transport our patients, each hospital providing a different level of emergent care.  We usually have all treatments completed based upon our protocols and orders from our medical control physician prior to the patient being flown off the island.  There are several reasons for this, but the main one is the transport aircraft needs to come from more than sixty miles away, and may sometimes be a US Coast Guard helicopter.  Weather is another issue that may delay transport for more hours.  There is seldom a time when the patient does not wait at least two hours for the flight to arrive of either the fixed wing aircraft or the helicopter.  The local EMS service provides the care for this extended time, as well as the care in the aircraft or helicopter throughout the air transport.  I hope this explains why we cannot finish the transport to the hospital.

We have developed an excellent rapport with our medical control physicians, who also provide bimonthly office hours at our local medical center.  After twenty years of experience with these physicians, we believe that they trust our judgment.

Now, as to the actual outcomes for the two patients mentioned.  Neither had a spinal injury per the ER physicians, who also function as the medical control physicians.  Also per these physicians, the spinal motion restriction was not necessary.  

While I agree that the patient is the responsibility of the transfer agency after patient care has been transferred, I don't understand the need to contradict  the medical control physician's orders.  

The transfer agency is taking the patient to the same medical control hospital with the same physician and the same protocols.  "It's our policy to immobilize patients like this" seems to be an invalid statement based upon two minutes of patient contact time with a five minute transport time to the medical control hospital.


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## reaper (Dec 13, 2008)

But it is their pt now. They are liable for that pt and can do what they feel needs to be done. If it was me and I felt that it warranted immobilization, then they would get it. The MD is not on scene and cannot see they pt. They allowed you to clear c-spine off what you told them. How do I know that you gave an accurate description of the pt and injuries?

Also, It does not matter if they pt had no spinal injuries, once the ED checked him out. How many Pt's that you immobilize, do you think have any real spinal injuries?

If you are worried about your agencies reputation, then you could have made it clear to the pt that they were being transfered to another agency. Once the pt is in their care, it is their pt, no longer yours. If the Md's had a problem with their treatment. Let them take it to their MD.


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## JPINFV (Dec 13, 2008)

reaper said:


> Also, It does not matter if they pt had no spinal injuries, once the ED checked him out. How many Pt's that you immobilize, do you think have any real spinal injuries?



I'd say it matters greatly. Since the current trend is moving towards selective spinal immobilization instead of immobilizing everyone with a boo boo, I'd say that any successful application of SSI (be it immobilizing patients with a high degree of suspicion of a spinal injury or not immobilizing patients with a low to no degree of suspicion) is a validation of that specific protocol. According to the OP, it's been correctly implemented twice with the transferring agency not using it. 

Now, the problem I see, and it might be just how it's worded, is if the final transport agency has the same medical director and the same SSI protocol, then why are they not using it?


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## VentMedic (Dec 13, 2008)

JPINFV said:


> Now, the problem I see, and it might be just how it's worded, is if the final transport agency has the same medical director and the same SSI protocol, then why are they not using it?


 
Or, one individual was more lenient with their assessment than another. Without very well established critieria for selective spinal immobilization, "opinions" and assessment will differ as to who gets immobilized. 

Dr. Bledsoe recently published this article about selective spinal immobilization:
http://www.ems1.com/columnists/bryan-bledsoe/articles/426350-Danger-at-the-Door

I will immobilize a patient as I see fit by my assessment and within the guidelines and protocols of my medical director.

The fact that this is even being discussed may be more of a peeing match between the agencies or individuals rather than a patient care issue.


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## medic5740 (Dec 13, 2008)

*Good Discussion*

Thanks for your comments.  Thanks to Ventmedic and his referral to Dr. Bledsoe's article.  I don't see this issue as a peeing match between agencies.  

I see this as a patient care scenario that needs discussion.  Should one EMS agency, with the same medical control physician, provide treatment that another agency did not provide?  That's the real issue. 

Does it make any difference to you if I tell you that I was the receiving EMS agency from a doctor's office, and I provided the spinal immobilization against that physician's orders? 

Does the medical control physician not still have complete control over the patient's treatment?  If a doctor on the scene orders you not to immobilize and your medical control doctor orders you to immobilize, I assume you follow your medical control physician's orders, or not?


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## VentMedic (Dec 13, 2008)

medic5740 said:


> Does the medical control physician not still have complete control over the patient's treatment?


 
Repeat:
The medical control physician gave YOU the orders based on YOUR assessment. 

The other paramedic could also have called in for all to hear with HIS assessment which may have differed form yours and what YOU might have missed. One or both parties could have lost some points on that one. The other Paramedic probably made his case for immobilization through documentation and HIS report.


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## mycrofft (Dec 15, 2008)

*Um, was it the same exact person making this sort of call??*

Maybe one or two MD's or microphone jockies can't follow the protocols? After all, "Mission Control" is always just a voice.


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