# When IFT=lower level of care/abandonment



## GloriousGabe (Dec 28, 2015)

I've always felt very odd about taking a PT from one facility to another where they have treated the PT with things I can't do in the ambulance. What happens when those things wear off? I'm pretty sure it's not legal, either. You can't t/f to a lower level of care. BLS is definitely a lower level of care from the ER. For ALS this isn't as much of a big problem as it is for BLS.


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## DesertMedic66 (Dec 28, 2015)

During transfers the patient is still technically under the care of the sending Doctor.


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## GloriousGabe (Dec 28, 2015)

DesertMedic66 said:


> During transfers the patient is still technically under the care of the sending Doctor.



How can the Dr tak care of that PT? If they dosed the patient with something and it wears off during transport how am I supposed to redose them? I'm only an EMT-B.


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## NomadicMedic (Dec 28, 2015)

Unless there is an actual intervention in progress, you should be fine. 

Patients receive treatment and are medicated all the time before being transported by a BLS unit. And if something happens, perform BLS and go to the hospital.


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## DesertMedic66 (Dec 28, 2015)

GloriousGabe said:


> How can the Dr tak care of that PT? If they dosed the patient with something and it wears off during transport how am I supposed to redose them? I'm only an EMT-B.


What kinds of medications is the hospital staff going to be giving that is going to wear off during transport for your BLS patients?

If you don't feel comfortable taking a patient from point A to point B with BLS resources then talk to the doctor and your supervisor. 

Our BLS units are 90% IFTs. Never once in the 2 years I was on BLS did I run into the issue of transporting a patient where something "wore off" during transport. If your patient has been having pain find out when the last time they were given pain meds was. Our hospitals are very good about giving pain meds 10 minutes before we load up. If the patient is going to need more pain meds in route then you should probably not take that patient at the BLS level without a nurse or doctor rider.


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## GloriousGabe (Dec 28, 2015)

It's never a discussion as to who we bring where. It's "take this PT to the truama center 90 miles away, now".

Had a seizure PT. Meds wore off. Seizing in ambualnce. What am I supposed to do?


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## Akulahawk (Dec 28, 2015)

The sending and receiving physicians confer and determine an appropriate level of care necessary for transport. I send patients out all the time (BLS even!) that are still receiving antibiotics or some other drip when the transport arrives. How do I keep them from exceeding their scope of practice? I don't let them take over care from me until the medication has completed. Sometimes the patient gets motion sick, so sometimes we'll give Zofran or something similar to the patient before transport to help prevent problems during transport. Here's how I prevent the crew from exceeding their scope of practice: I administer the medication, sign it off, advise the crew what I've done and what to expect (if necessary). Once I turn the patient over to the crew, I do NOT intervene after that unless it's absolutely necessary as it's their patient now. 

Something I do is "allow" the crew to take over care to provide better care than I can at that particular time. I know what protocols the crews function under and sometimes I'll advise them that they may want to follow their protocols for providing care... because sometimes it may take me longer to obtain an order for something and administer it than it would for the crew to do the same thing. 

As an IFT provider, _you_ also have the responsibility to recognize when the patient requires care beyond your ability to provide. While a patient may be intended to be sent out BLS, if the patient is unstable, it's your job to recognize that and refuse to do the transport at that level. I have refused transports because the patient wasn't stable for BLS (or even ALS) transport. I have told sending facilities that the patient needs further stabilization before I could accept the patient. Those few times I have done this, the patient really did need additional care and I was glad to accept the patient later when the patient had been stabilized sufficient for transport... and the facility usually thanked me for my attentiveness as it prevented them from getting into trouble for sending out a patient inappropriately.


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## DesertMedic66 (Dec 28, 2015)

GloriousGabe said:


> It's never a discussion as to who we bring where. It's "take this PT to the truama center 90 miles away, now".
> 
> Had a seizure PT. Meds wore off. Seizing in ambualnce. What am I supposed to do?


Treat the patient as a BLS provider and made a decision on what is going to be best for the patient (contact an ALS unit, divert to the closest hospital, or continue transport to the original destination).


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## Akulahawk (Dec 28, 2015)

GloriousGabe said:


> It's never a discussion as to who we bring where. It's "take this PT to the truama center 90 miles away, now".
> 
> Had a seizure PT. Meds wore off. Seizing in ambualnce. What am I supposed to do?


If you're BLS and you need to take a trauma patient 90 miles to a trauma center, and the patient is likely to need ALS intervention during transport, you need to bring that up. If you have a seizing patient, you don't have to do much... you keep the patient safe, apply oxygen as necessary, provide ventilatory support PRN, and transport to the closest, most appropriate facility. What would you do with that same patient in the 911 arena? Most of the time you don't have to do much beyond that. You need to think about your options... and that may include calling for ALS.


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## Chimpie (Dec 28, 2015)

GloriousGabe said:


> Had a seizure PT. Meds wore off. Seizing in ambualnce. What am I supposed to do?


What would you normally do if you had a patient in your ambulance and they start seizing?

The protocol is the same.


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## ERDoc (Dec 28, 2015)

A large portion of the burden falls on the sending doc.  They are responsible for making sure they are requesting the proper level of care for the transfer.  Any trauma pt should be going ALS unless it is isolated ortho trauma.  I think more info is needed from the OP but something doesn't sound right about the transfer.  Anyone remember that bad premie case in Florida a few years ago?

http://ems-law.net/2011/05/20/10-million-verdict-in-florida/


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## GloriousGabe (Dec 28, 2015)

It just doesn't make sense. In order for that "higher level of care" to happen those folks need to be present. Sending a PT in my BLS bus is definitely a lower level of care and definitely abandonment. If the PT were to code and die I bet a lawyer would have a field day. I've already been sued three times. I don't need a fourth!!!!


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## Jim37F (Dec 28, 2015)

As the attending EMT the onus is on you to say "I don't feel comfortable taking this patient, I don't believe they are stable enough for BLS transport" and then call for ALS. However, I believe you had said in a previous thread that you only have one medic unit available for a 3 county area or something like that? So if ALS simply is not available, and the patient NEEDS the higher level of care (say your trauma patient needs the surgeons at the trauma center) then what? Just let the patient die in the ER simply because?


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## MonkeyArrow (Dec 28, 2015)

GloriousGabe said:


> It just doesn't make sense. In order for that "higher level of care" to happen those folks need to be present. Sending a PT in my BLS bus is definitely a lower level of care and definitely abandonment. If the PT were to code and die I bet a lawyer would have a field day. I've already been sued three times. I don't need a fourth!!!!


Sometimes, you have to stop worrying about being sued. You've already mentioned that you've been sued multiple times in multiple threads. To a point, we already practice defensive medicine but if you have that thought constantly hanging in the back of your mind about getting sued, you won't be able to perform properly. Anecdotally, I work with an ER doc who has been sued and overorders a lot of unneeded tests and labs (he has built quite the reputation of ordering everything under the sun) and just practices medicine unlike any other doc presumably because he's scared of getting sued again. Now whether you are doing something wrong that you are getting sued as a BLS provider three times is a different discussion.


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## DesertMedic66 (Dec 28, 2015)

The patient needs to be stable enough to be transported by whatever means the doctor feels is the best. 

If you don't feel comfortable taking a transport then don't. If something is out of your scope of practice then don't do it. 

As for being sued 3 times: http://www.hpso.com


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## squirrel15 (Dec 28, 2015)

I don't understand what in the world you're doing that you have been sued three times as a basic, but I digress. In order to transport mostly the patient will be handed over to a lower level of care, even ALS is a lower level of care. Its your responsibility to make sure the patient has been given appropriate meds before leaving. If a patient was given pain meds and those magically wear off, I'm sorry the patient may be in some pain during the rest of the transport, but the receiving meds should be able to fix that when we get there.

BLS IFT is pretty simple, and the patients are most likely stable. If you feel a patient isn't stable, talk to the doc and your supervisor and refuse the transport. That easy.


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## Akulahawk (Dec 29, 2015)

GloriousGabe said:


> It just doesn't make sense. In order for that "higher level of care" to happen those folks need to be present. Sending a PT in my BLS bus is definitely a lower level of care and *definitely abandonment*. If the PT were to code and die I bet a lawyer would have a field day. I've already been sued three times. I don't need a fourth!!!!


You probably need to have someone sit down with you and truly school you about things like "abandonment" and "negligence" and "competence." You do not seem to understand these things as it pertains to EMS, and medicine in general. What you also need to understand is that sometimes a patient that's very sick only truly needs BLS for transport but also needs the surgeon waiting for them on the other end. As I've said earlier, if you're not comfortable taking a patient because you believe and can clearly articulate _why_ a patient requires care beyond your ability, it's incumbent upon YOU to speak up and say so. Worst case scenario is the sending facility must send someone that's qualified to provide the level of care necessary. However, the onus is primarily on the sending facility to determine the appropriate level of care necessary during transport. They may not exactly know your limitations, but they know that if a patient doesn't need a monitor or doesn't need anything other than a basic IV fluid running during transport, BLS is appropriate. ALS can do many things... but the choice of CCT-RN is necessary if the patient requires ICU level care during transport. They know those basics... and if YOU know those differences, YOU can help them choose the most appropriate transport resource and it may NOT be your company.


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## ERDoc (Dec 29, 2015)

I think this is where EMS education is lacking.  The problem is that a lot of BLS people don't know when they are getting in over their heads.  They don't know what they don't know.  If I am the sending physician, I am responsible for deciding what level of care is needed, if that level cannot be found then it falls on me to manage that pt until the appropriate level of care can be found.  If something goes wrong, I am going to be on the hook.  Why do you think the doctors in that Florida case settled?  They knew they were hosed.  Luckily for me, every ambulance around here has medics and many have CCT medics when needed.


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## RedAirplane (Dec 29, 2015)

As I was taught, you can't go down, you can only go up. Otherwise it's abandonment.

EMT can accept patient from EMR or EMT
Paramedic can accept from EMR, EMT, or Paramedic
Doctor can accept anyone because they're the "highest"

There are several flaws in this (does nobody ever get discharged? Do all transfers need MDs?) but this is the very simple way things are explained in an EMR or EMT class.


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## DesertMedic66 (Dec 29, 2015)

RedAirplane said:


> As I was taught, you can't go down, you can only go up. Otherwise it's abandonment.
> 
> EMT can accept patient from EMR or EMT
> Paramedic can accept from EMR, EMT, or Paramedic
> ...


That's going to be system dependent. There are a number of systems where paramedics will hand over care to an AEMT or EMT. I believe  Los Angeles does this (fire medics and private BLS company responds to all 911 calls, the medic assess the patient and then deems the patient needs ALS or BLS).


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## Jim37F (Dec 29, 2015)

DesertMedic66 said:


> That's going to be system dependent. There are a number of systems where paramedics will hand over care to an AEMT or EMT. I believe  Los Angeles does this (fire medics and private BLS company responds to all 911 calls, the medic assess the patient and then deems the patient needs ALS or BLS).


Pretty much. If they determine the patient is BLS the fire medics go available and the private EMTs transport the patient themselves. Perfectly legal, and written into our county protocols. It's also written into our protocols that if the BLS transport time is less than the ETA of the medic unit, the EMTs can load and go, so while due to the large number of ALS units (both fire and private ambulances) it'll never happen, but in the OPs scenario here if there were no ALS units available, the EMT BLS ambulance can legally transport an ALS patient to the higher level care, such as the example given of the trauma patient going from the "doc-in-a-box" community hospital to the trauma center (especially if the sending MD says the patient can't wait).


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## FiremanMike (Dec 29, 2015)

GloriousGabe said:


> How can the Dr tak care of that PT? If they dosed the patient with something and it wears off during transport how am I supposed to redose them? I'm only an EMT-B.



Just like off-line protocols, the doc will not be directly involved but will be absolutely responsible for everything that occurs until your patient until they reach the receiving facility.


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## exodus (Dec 29, 2015)

GloriousGabe said:


> It just doesn't make sense. In order for that "higher level of care" to happen those folks need to be present. Sending a PT in my BLS bus is definitely a lower level of care and definitely abandonment. If the PT were to code and die I bet a lawyer would have a field day. I've already been sued three times. I don't need a fourth!!!!



Holy ****, if you have been sued 3 times you are not a good provider and need to find a new job. If one person finds you an *******, chances are it's them. If EVERYONE find you an *******. It's you.

If you have issues with the IFT protocols in your area bring it up to your EMS authority.  But I digress, sued 3 times a basic... Do something else.


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## FiremanMike (Dec 29, 2015)

I hit 17 years this year, 15 years with a high volume system.  I've also worked part time jobs at rural departments, in critical care, and in HEMS.  I've been sued 0 times..  Either you are exaggerating or you're doing something very, very wrong.

On a final note, it is definitely not abandonment, as has been explained ad nauseam.  You are functioning as an extended arm of the sending physician who has the ultimate responsibility for your patient until you reach the receiving facility.  By your logic, it is abandonment when the physician leaves the patient's room in the care of the RN while he goes to see another patient or to eat lunch.


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## Akulahawk (Dec 29, 2015)

RedAirplane said:


> As I was taught, you can't go down, you can only go up. Otherwise it's abandonment.
> 
> EMT can accept patient from EMR or EMT
> Paramedic can accept from EMR, EMT, or Paramedic
> ...


When I'm on scene with a patient, if my assessment tells me that the patient is OK for  BLS care, then I can triage the patient to my EMT partner. If my EMT partner refuses the patient, then I cannot force the patient onto my partner. The fact that I'm also an RN doesn't mean that I cannot triage my patient "back down" to BLS as long as the patient meets criteria for BLS care. The only time I cannot triage a patient to a lower level of care is if that patient requires care that the lower level of care cannot provide for the duration expected. 

In an IFT setting, the "rules" are different from the usual prehospital rules.


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## ERDoc (Dec 29, 2015)

This only applies to NYS as far as I know but when I was a volley, the question of ALS handing a pt off to BLS came up and the question was actually sent to the state DOH.  Their reply was that on a BLS call, everyone is a BLS provider so the pt can be handed off to someone else with a BLS cert even if the person doing the handoff is certified at the ALS level.  The ALS provider becomes an ALS provider when the pt need ALS interventions at which point the pt cannot be handed off to a BLS provider.


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## TransportJockey (Dec 29, 2015)

To the OP, in your opinion if I do a 12-lead to  clear a patient to be taken by BLS, is that abandoment? Cause it seems no more out of the ordinary to me than your other scenarios


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## ERDoc (Dec 29, 2015)

I'd still like to know more about the original scenario.  Why was this person being transferred?  What meds were given?  Did the person have a previous seizure history?


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## Ensihoitaja (Dec 29, 2015)

Really, the biggest issue is making sure the patients needs are met when transferring care. If the patient needs ALS care, then clearly handing them off to a BLS unit is inappropriate. If the patient needs CCT care then an ALS ambulance is inappropriate. 

I've worked in systems when an ALS ambulance could transfer care to a BLS ambulance, it's really not that different from a medic/basic ambulance and having the basic attend.


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## Gurby (Dec 29, 2015)

ERDoc said:


> I'd still like to know more about the original scenario.  Why was this person being transferred?  What meds were given?  Did the person have a previous seizure history?



I think I scared him by talking in chat about a call I had just done:  IFT for a patient with glioblastoma, going from community hospital to big city hospital ED.  Patient is very agitated, gets some Ativan just before transport.  Patient starts seizing while we're waiting in triage, causing excitement and getting us to the front of the line.  I joked that "the Ativan wore off just in time".


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## GloriousGabe (Dec 29, 2015)

TransportJockey said:


> To the OP, in your opinion if I do a 12-lead to  clear a patient to be taken by BLS, is that abandoment? Cause it seems no more out of the ordinary to me than your other scenarios


Way outside of my scope. What...I'm supposed to bring a 12 lead from home?!


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## squirrel15 (Dec 29, 2015)

GloriousGabe said:


> Way outside of my scope. What...I'm supposed to bring a 12 lead from home?!


The twelve lead is done, you don't need to do one. But I have a new bridge for sale if the one your under is getting aged


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## StCEMT (Dec 29, 2015)

GloriousGabe said:


> Way outside of my scope. What...I'm supposed to bring a 12 lead from home?!


You weren't the one doing the 12 lead in that hypothetical, Transport Jockey was...


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## Akulahawk (Dec 29, 2015)

Please keep things civil.


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## Chimpie (Dec 29, 2015)

GloriousGabe said:


> Way outside of my scope. What...I'm supposed to bring a 12 lead from home?!


What was your point with this statement?


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## GloriousGabe (Dec 30, 2015)

Chimpie said:


> What was your point with this statement?



That I only operate within my scope of practice. BLS doesn't have 12 leeds.


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## StCEMT (Dec 30, 2015)

You ARENT doing a 12 lead based on what TransportJockey said, so you are within your scope. Where are you confused with that statement?


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## GloriousGabe (Dec 30, 2015)

StCEMT said:


> You ARENT doing a 12 lead based on what TransportJockey said, so you are within your scope. Where are you confused with that statement?


Maybe. Sorry. It's been a long day.


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## Akulahawk (Dec 30, 2015)

GloriousGabe said:


> That I only operate within my scope of practice. *BLS doesn't have 12 leeds*.


While this is true, a _Paramedic_ has done the 12 lead and has triaged the patient down to BLS. Could you bring the 12 lead printout with you? Sure. That still doesn't mean that the patient still _needs _ALS level care during transport. The "downgrade" of patients from ALS to BLS happens all the time all over the country.


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## Jim37F (Dec 30, 2015)

Akulahawk said:


> The "downgrade" of patients from ALS to BLS happens all the time all over the country.


As does the "downgrade" of patients from the care of a Doctor to BLS ambulances for inter-facility transports with out a problem.


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## reaper (Dec 30, 2015)

GloriousGabe said:


> Way outside of my scope. What...I'm supposed to bring a 12 lead from home?!


Learning and education come to mind.


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## GloriousGabe (Dec 30, 2015)

reaper said:


> Learning and education come to mind.


How? No medic school for hours.


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## DesertMedic66 (Dec 30, 2015)

Continued education classes. College level science classes. Online research. Books.


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## GloriousGabe (Dec 30, 2015)

DesertMedic66 said:


> Continued education classes. College level science classes. Online research. Books.



No library card. Was revoked.


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## StCEMT (Dec 30, 2015)

Google dude....Google....You can find information on pretty much anything you want to know if you look....please....use it...


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## squirrel15 (Dec 30, 2015)

GloriousGabe said:


> No library card. Was revoked.


Is that because you were sued so many times? The library deemed you irresponsible?


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## DesertMedic66 (Dec 30, 2015)

GloriousGabe said:


> No library card. Was revoked.


But apparently your internet privileges have not been revoked.


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## Chimpie (Dec 30, 2015)

*Closing this thread for 48 hours to let everyone cool off a bit.*


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