# La County protocol question



## Frozin (May 7, 2014)

Hello

Prior to posting this I searched the internet and read through the protocols, at least from what I thought were the correct protocols for LA county. 

There is a bit of disagreement i've been having with some EMT's at my BLS ambulance company that does only IFT. They have been saying there is an LA county protocol saying that we aren't allowed to transport a patient with a BP above 200. Is this true? If so, can someone be kind enough to link me the protocol.


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## LACoGurneyjockey (May 7, 2014)

No. No. Noooooooo. There is no such protocol and anyone who says so has NOT read the protocol (good on you for doing some light reading). This BS is all over those LA IFTs and it's just not founded in anything. 
There is no vital sign that prohibits you from BLS transport in LA Co, except a respiratory rate greater than 24, or 30, can't remember which. Basically just Respiratory distress is an ALS complaint. 
Now go save those kidneys!

Edit: your *company* may have such a policy though, so make sure.
Also, BP lower than 90 systolic with signs of shock is a no no.


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## Frozin (May 7, 2014)

LACoGurneyjockey said:


> No. No. Noooooooo. There is no such protocol and anyone who says so has NOT read the protocol (good on you for doing some light reading). This BS is all over those LA IFTs and it's just not founded in anything.
> There is no vital sign that prohibits you from BLS transport in LA Co, except a respiratory rate greater than 24, or 30, can't remember which. Basically just Respiratory distress is an ALS complaint.
> Now go save those kidneys!
> 
> ...



Thanks!


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## Uclabruin103 (May 7, 2014)

Just to clarify,  the specific respiratory rate of 29 has to do when trauma is involved. Policy 506. This is the same with BP < 90. Now 808 says base hospital contact I. E. ALS level call when a patient is SOB or tachypnea and also for patients with signs and symptoms of shock.


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## Chupathangy (May 8, 2014)

LACoGurneyjockey said:


> Also, BP lower than 90 systolic with signs of shock is a no no.



Yeah, in my county its 90 with signs of shock, or less than 80 systolic. If you're close enough to the ED and you dont sound entirely incompetent over the radio theyll let you come in.


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## Quikclot (May 11, 2014)

As a side note, always keep your protocols handy. I use PPP (acidremap.com or on App Store) to keep my protocols handy and current. The $10 is worth it...don't bother with the free version. LA County is on there and I also download my neighboring counties in case of mutual aid or an outside agency assist call.

Very handy.


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## chaz90 (May 11, 2014)

Quikclot said:


> As a side note, always keep your protocols handy. I use PPP (acidremap.com or on App Store) to keep my protocols handy and current. The $10 is worth it...don't bother with the free version. LA County is on there and I also download my neighboring counties in case of mutual aid or an outside agency assist call.
> 
> Very handy.



Certainly good advice regarding PPP, but I've never heard of using someone else's protocols whether on mutual aid or some kind of agency assist. An understanding exists that if an outside agency is called into your jurisdiction, they'll still be operating under their own protocols. We routinely transport to hospitals outside our state along with running calls just over the border into Maryland as well. Even though Maryland and Delaware both have statewide protocols with some fairly significant differences, we would never dream of trying to operate under MD protocols even out of state.


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## Quikclot (May 11, 2014)

Ahh well, probably has something to do with California and/or AMR. I've never run into a real difference in protocols on the ones I've run but knowing this area, I can see my Medic getting drama over a meds difference if we were requested to take a call in another county, although granted there aren't a lot of differences.


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## Tigger (May 11, 2014)

There would be problems if I chose to operate outside of the protocols that my medical director has provided with me, no matter where I am. I can't imagine that not being the case everywhere.


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## Quikclot (May 11, 2014)

Could be my mistake then. I'll have to clarify. Thanks for the noggin jolt.


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## NPO (Jun 14, 2014)

I believe its the SFTP policy that lists ALS criteria. A buddy of mine in LACoFD said they just added "suspected hip fracture" to the list, requiring many upset paramedics to ride in on slip and falls with hip pain. Regardless, its a good policy to have if you want to run down the ALS check list.

Also, fun fact, BLS has to take to the MAR in all emergency cases except penetrating thoracic trauma with SBP


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## NPO (Jun 14, 2014)

chaz90 said:


> Certainly good advice regarding PPP, but I've never heard of using someone else's protocols whether on mutual aid or some kind of agency assist. An understanding exists that if an outside agency is called into your jurisdiction, they'll still be operating under their own protocols. We routinely transport to hospitals outside our state along with running calls just over the border into Maryland as well. Even though Maryland and Delaware both have statewide protocols with some fairly significant differences, we would never dream of trying to operate under MD protocols even out of state.



We respond into another county often. Our medics used to be dual accredited but it meant that when they crossed the border their scope shrank. So we are back to single accreditation.


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## BASICallyEMT (Jun 14, 2014)

My last company was a IFT in LA. We could not transport anything over 190 or less than 90. I can't recall seeing a protocol that states that so I assume it was the companies preference.


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## Uclabruin103 (Jun 14, 2014)

NPO said:


> I believe its the SFTP policy that lists ALS criteria. A buddy of mine in LACoFD said they just added "suspected hip fracture" to the list, requiring many upset paramedics to ride in on slip and falls with hip pain. Regardless, its a good policy to have if you want to run down the ALS check list.
> 
> Also, fun fact, BLS has to take to the MAR in all emergency cases except penetrating thoracic trauma with SBP



Not to sound like a ****, but you really need to look at the policies for yourself and not just listen to others. EMT can honor destinations that aren't the MAR. And know that for a pediatric the MAR is the closest EDAP. Policy 808 tells what needs to be transported and how. Hip fractures have always been a mandatory transport in the four years I've worked here. County fire might have their own policy on whether it has to be ALS. 

Next time you're at work posting or not running calls look at your policies. If you're going medic it will only help. I recommend 506 808 814 502 815 as a good starting point. 502 is what you can look at for patient destination like where an EMT  can take patients. 

They're there for you to look at and study and not have to take the word of others.


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## NPO (Jun 14, 2014)

Uclabruin103 said:


> Not to sound like a ****, but you really need to look at the policies for yourself and not just listen to others. EMT can honor destinations that aren't the MAR. And know that for a pediatric the MAR is the closest EDAP. Policy 808 tells what needs to be transported and how. Hip fractures have always been a mandatory transport in the four years I've worked here. County fire might have their own policy on whether it has to be ALS.
> 
> Next time you're at work posting or not running calls look at your policies. If you're going medic it will only help. I recommend 506 808 814 502 815 as a good starting point. 502 is what you can look at for patient destination like where an EMT  can take patients.
> 
> They're there for you to look at and study and not have to take the word of others.



I typed out more but it didn't go through. I know a patient can request diversion to a hospital that's not the MAR if they are stable and BLS. I typed that at the end something to the effect of "other than the stable patient diversion request."

Thanks for the policy references, however I probably won't read them (again) since I know them and don't work there any more


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## Jim37F (Jun 14, 2014)

I just looked through on the County's EMS Agency website and didn't see anything about transport of patients with a SBP of 200. 

My dept policy only says ALS OR BLS transport is required in that case, but is not a base contact criteria if asymptomatic, so I personally don't see why you can't take that patient. 

Now if your particular company has a written policy saying you can't, then that's a different story. If it's an unwritten rule, I'd say call one of your supervisors or dispatch to make that call officially.


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## Ewok Jerky (Jun 14, 2014)

So if your patient is shocky (BP<90), you ARE NOT supposed to take them to the ED?  Need to wait on scene for a medic to come start a line?

Also, while I am not in LA, you really should know your protocols for yourself.  First, so you don't get yourself in trouble, second so that if someone else gets you in trouble, you don't look like an idiot for not knowing what the rules are and following the crowd or letting your partner make a bad decision because you both are ignorent of the regulations.


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## NPO (Jun 14, 2014)

County doesn't have a policy saying anything about vitals that I've seem. Just symptoms/conditions in which they want ALS transport. However that is all superseded by Policy 502 if the patient had an immediate life threat, BLS may transport to the ER of the ALS ETA is longer than transport ETA. And let's be honest, in LA responses aren't super quick and there a hospital next to every Starbucks.


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## Chris07 (Jun 15, 2014)

There's a good part of the county where transport to MAR is about 15-20 minutes, and not remote/mountainous/wilderness areas either. I'm talking about regular full blown cities. It's not often ALS responses are greater than 15 minutes, perhaps when it's really busy yes, but when it's that busy typically everyone's response is much slower. From my experience with County Fire (take at face value) I'd say an average ALS response time is about 8-9 minutes. Cities with RAs, ALS Engines and such I'd suspect are a bit less than that

Now if you're an IFT company EMT, I don't necessarily think you're always going to know where the nearest fire station with ALS is (and if the 911 system is busy for that matter). That's really the case they're trying to cover. It's always _your_ decision. Do you believe you can get them to a MAR quicker? Yes? Then do it, but if you're quite a ways from the MAR, it's probably a good bet ALS will get there first.

If you do decide to transport, try and call ahead. If you walk in with a sick patient unannounced, you're not going to be winning any popularity contests. Even 1 minute's advanced notice is better than nothing.


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## LACoGurneyjockey (Jun 15, 2014)

beano said:


> Also, while I am not in LA, you really should know your protocols for yourself.  First, so you don't get yourself in trouble, second so that if someone else gets you in trouble, you don't look like an idiot for not knowing what the rules are and following the crowd or letting your partner make a bad decision because you both are ignorent of the regulations.



You overlook the fact that we're talking about LA County EMS, where knowing your protocol comes second to making sure you get Ms Brown to her dialysis treatment no less than 5 minutes early, and diverting to the ER is seen as unnecessary, extra paperwork, ricky rescue-ness. 
GET OUT WHILE YOU STILL CAN!


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## sean818 (Jun 27, 2014)

*A question reagrding policy 502*

Can anyone elaborate on 'principle 3' of policy 502, specifically in regards to EMTALA. Principle 3 states that "The most appropriate receiving facility for a patient may be the health facility which is affiliated with their health plan." I'm very new to EMS having just been certified by the state and awaiting my first interview so my knowledge is limited, but wouldn't this be somewhat of an EMTALA violation as it's suggesting choosing a receiving hospital based on a patient's health coverage? I understand that if a patient has a regular hospital they go to and they specifically request to be transported there it's up to them but where do we draw the line in order to avoid getting in trouble? Any help is appreciated, I may just be reading this incorrectly.


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## DesertMedic66 (Jun 27, 2014)

Patients are able to choose the hospital they want to be transported to (within reason). We have one hospital in my area that does not accept Kaiser insurance. If the patient is stable then we will transport them to a hospital that accepts it. If the patient is critical then we will transport to the closest facility.


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## PotatoMedic (Jun 27, 2014)

I thought all Er's were required to accept any insurance for er visits.


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## sean818 (Jun 27, 2014)

DesertEMT66 said:


> Patients are able to choose the hospital they want to be transported to (within reason). We have one hospital in my area that does not accept Kaiser insurance. If the patient is stable then we will transport them to a hospital that accepts it. If the patient is critical then we will transport to the closest facility.



This is exactly what's confusing me. Isn't it illegal to choose a hospital based on insurance, whether or not the patients stable? Unless of course the patient requests a certain hospital


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## STXmedic (Jun 27, 2014)

Why would it be illegal?* If somebody made a law that prohibited a stable patient from being transported to a hospital so that insurance would cover it, thereby putting the patient under unnecessary financial strain, that lawmaker should be hung.

*I have no idea if it is or is not illegal in CA.


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## DesertMedic66 (Jun 27, 2014)

FireWA1 said:


> I thought all Er's were required to accept any insurance for er visits.



Our hospital will transfer out all Kaiser patients and all kaiser patients know to not go to that hospital.


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## DesertMedic66 (Jun 27, 2014)

sean818 said:


> This is exactly what's confusing me. Isn't it illegal to choose a hospital based on insurance, whether or not the patients stable? Unless of course the patient requests a certain hospital



Not to my knowledge. It is in the patients best interest to transport them to that hospital.


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## NPO (Jun 27, 2014)

FireWA1 said:


> I thought all Er's were required to accept any insurance for er visits.



A hospital is required by law to treat and stabilize within the abilities of their facilities and staff any life threatening condition regardless of ability to pay or insurance affiliations. 

Its no stretch of the imagination to see how a kaiser patient can benefit from a kaiser network hospital.. (To continue the example) access to records, no billing issues, etc. A non kaiser facility may bill for services kaiser may not approve, or cover the same as an in network facility. 

When reasonable we should honor patient requests for where to go especially if it means their insurance will cover visits and won't leave them broke. 

In my county we ask every patient where they want to go and hardly ever override their request unless its a case specific issue and they requested a facility not equipped for the condition, and this doesnt happen often.


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## DesertMedic66 (Jun 27, 2014)

NPO said:


> A hospital is required by law to treat and stabilize within the abilities of their facilities and staff any life threatening condition regardless of ability to pay or insurance affiliations.
> 
> Its no stretch of the imagination to see how a kaiser patient can benefit from a kaiser network hospital.. (Go continue the example) Access to records, no billing issues, etc. A non kaiser facility may bill for services kaiser may not approve, or cover the same as an in network facility.
> 
> ...



This exact wording. We also ask every single patient.


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## PotatoMedic (Jun 27, 2014)

We have a similar hospital system here.  They don't have an "er" that is classified as an urgent care so legally they don't have to anyone except people in their system.  I must have misunderstood what someone said.  So yeah.  Unless they will die by not going there it makes sense to go to the place that will care for them the best.


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## sean818 (Jun 27, 2014)

Thank you for clarifying everybody that makes alot more sense than what I was thinking. My teacher made it very clear to never choose a hospital based on insurance and definitely never to mention the insurance to the hospital that you plan on transporting to but I guess that would mainly apply to true emergencies. Glad I found this forum before I start working


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## sean818 (Jun 27, 2014)

STXmedic said:


> Why would it be illegal?* If somebody made a law that prohibited a stable patient from being transported to a hospital so that insurance would cover it, thereby putting the patient under unnecessary financial strain, that lawmaker should be hung.
> 
> *I have no idea if it is or is not illegal in CA.



Lol, I honestly wouldn't expect much more from california. Seems to be the most ***-backwards state in existence


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