Prime Example of Why LA County EMS is a Broken System

[thegreypilgrim]

I actually witnessed these unfortunate events which exemplify nearly everything that's wrong with the system here.

Middle aged male comes in to an urgent care clinic with some atypical ACS symptoms. From what I gathered it was substernal chest pain, non-radiating, progressive onset (but rather rapidly), with lower back pain. Apparently after ASA and NTG admin, the chest pain subsided but back pain persisted. Vitals seemed to be holding within normal limits from what I heard.

Anyway, physician on duty had called 911 because he thought it was an AMI based off presentation and 12-lead. FD medics show up, essentially act like this is a BS call; and, apparently there was some sort of problem with the 12-lead. The "problem" was the repeat 12-lead done by EMS didn't print out with a "***STEMI" interpretation from the monitor.

Paramedics in LA cannot interpret a 12-lead, they have to go by the computerized interpretation of the monitor.

MEDIC: Doc, did your 12-lead printout say "STEMI"?
DOCTOR: No, but you can clearly see the elevation in V1 and V2 here.
MEDIC: But the printout didn't say STEMI.
DOCTOR: No.

Paramedics here cannot take medical direction/orders from anything other than a base hospital physician (i.e. calling medical control) unless there is a physician on scene who then must accompany the paramedics (meaning he must leave his clinic with all the other patients there) to the hospital.

Patient ended up being transported to the closest ED which was not a STEMI receiving center. My question is, if this patient was indeed undergoing an AMI, how was this patient "served" by the EMS system here?

 

[usafmedic45]

Paramedics in LA cannot interpret a 12-lead, they have to go by the computerized interpretation of the monitor.

That's just frightening. Personally, I don't care what the protocol says, that patient would have gone somewhere with a cath lab.

Paramedics here cannot take medical direction/orders from anything other than a base hospital physician (i.e. calling medical control) unless there is a physician on scene who then must accompany the paramedics (meaning he must leave his clinic with all the other patients there) to the hospital.

Then you call medical control, tell the doc on scene to repeat what he told you to the medical control physician and go from there. It sounds more like a combination of stupid medics and bad protocols than bad protocols alone.

 

[Veneficus]

Then you call medical control, tell the doc on scene to repeat what he told you to the medical control physician and go from there. It sounds more like a combination of stupid medics and bad protocols than bad protocols alone.

That is when the doctor should ask for your medical control number and call himself. Nothing moves the system like an attending (Consultant) speaking with another.

Another solution is for that facility to have a contract with an IFT company that brings a little higher quality to the table.

 

[thegreypilgrim]

That's just frightening. Personally, I don't care what the protocol says, that patient would have gone somewhere with a cath lab.

No kidding. I can't imagine someone being upset with me for "overstepping my bounds" and interpreting the 12-lead (which I actually know how to do) and transporting to a STEMI center. I just wouldn't know what to say in that situation.

Then you call medical control, tell the doc on scene to repeat what he told you to the medical control physician and go from there. It sounds more like a combination of stupid medics and bad protocols than bad protocols alone.

That definitely sounds like the rational option here. And the terrible medics + bad protocols thing is exactly what I was trying to convey with this story.

 

[usafmedic45]

I just wouldn't know what to say in that situation.

"Hey, this guy has ST elevation and the computer didn't catch it. When do I get my cookie?"

That definitely sounds like the rational option here. And the terrible medics + bad protocols thing is exactly what I was trying to convey with this story.

Trust me, I know how frustrating that can be. I used to work for a medical director cleaning up services like that.

 

[thegreypilgrim]

That is when the doctor should ask for your medical control number and call himself. Nothing moves the system like an attending (Consultant) speaking with another.

Yeah, it's pretty remarkable that no one thought to do this or the medics didn't afford the attending at the clinic the option to speak to med control.

Another solution is for that facility to have a contract with an IFT company that brings a little higher quality to the table.

Unfortunately, private IFT services cannot be used to replaced the "first-in 911" provider (in some cases this is a good thing). Most private companies here use a 1-on-1 configuration (1 medic with 1 EMT) and in order to transport calls that would normally be considered "emergency" the unit must be dual-medic. See LACo Ref. 517:

Thus, if an ALS IFT unit responded to this call, they would be obligated to activate 911 depending on transport time to the nearest STEMI center.

 

[46Young]

Another solution is for that facility to have a contract with an IFT company that brings a little higher quality to the table.

Some local FD's or muni EMS agencies shut out the local privates from doing pickups from NH's, Asst Living facilities, MD offices, etc. I know that in my own county we run all the Kaisers, Sunrises, independent NH's, and pretty much all of the MD offices. It's pretty much guaranteed income, but the local houses get sick of running 10 Spring Village txps a day, six or seven Kaisers, or "hitting for the cycle" by running all four local NH's in one day.

When I first started my IFT PT job, I made several suggestions to increase their revenue. I asked why they weren't pursuing contracts with MD offices. I was told that the county controls that. Same for all the NH's, Asst Livings, and Kaiser offices. I also suggested that they could enter into a contract with certain towns that are 100% volunteer run to staff a 24/7 ALS unit, or even just one for the daytime. Not happening.

 

[thegreypilgrim]

"Hey, this guy has ST elevation and the computer didn't catch it. When do I get my cookie?"

Ha! Once I got my cookie though I'm sure it would be mercilessly demolished by my employer after the angry phone call they received from the FD representative chastising them for "jumping calls". You just aren't meant to have cookies in this world.

Trust me, I know how frustrating that can be. I used to work for a medical director cleaning up services like that.

It's improved somewhat over the passed couple years. For instance we can now give a whopping 4 mg of morphine prior to contacting med control for isolated extremity injuries (woohoo!!). There will never be much autonomy here though with all the medic mills in operation here churning out firefighters forced to become paramedics who were never taught to national standards.

 

[JPINFV]

"Hey, this guy has ST elevation and the computer didn't catch it. When do I get my cookie?"

How about "This guy has ST elevation, the comptuer didn't catch it, and the transporting physician has interpreted the 12 lead as a STEMI.

 

[CAOX3]

How about be proactive and assume the guy with the MD after his name might know a little more then the box with the squiggly lines.

 

[JPINFV]

Thus, if an ALS IFT unit responded to this call, they would be obligated to activate 911 depending on transport time to the nearest STEMI center.

(II)(A)(2)(a) seems to allow this considering that an urgent care center is a health care facility. (I)(B)(6) disallows paramedics from accepting orders from a base hospital, however this could be handled in two ways.

1. Base hospital contact. We have a physician confirmed STEMI, can we go to a STEMI center?

2. Base hospital contact (I believe it would be required anyways). Physician wants to transfer a STEMI patient to a STEMI center (initial destination), patient has chest pain, do you want us to divert. (covered under section (I)(B)(4) ).

 

[usafmedic45]

I don't know....there are a couple of docs at the hospital I work at whose word I trust less than the assessment of the EKG machine. (Sorry...I couldn't help but be a smartass on this one)

 

[alphatrauma]

Prime Example of Why LA County EMS is a Broken System


... FD medics show up, essentially act like this is a BS call

I don't think this is a problem exclusive to LA. I have seen this very same thing in my area. I work (less frequently now) for a "doc in the box", and it never fails when we call for EMS, the FD Medics come in with the "why are we here" attitude, and challenging the physician's judgment. How about taking report and transporting the patient appropriately? It's not like we're going to say, "never mind". When I was in medic school, my co-workers made me promise that I would not become one of those DBs.

If a Paramedic cannot competently perform a basic 12 lead interpretation (I realize we are not Cardiologists), they have no business acting as AIC.

This is what happens, when you force fire guys to run EMS calls.

 

[thegreypilgrim]

(II)(A)(2)(a) seems to allow this considering that an urgent care center is a health care facility.

That's why I added the qualifier "depending on transport time to nearest STEMI center". If the IFT unit can get the patient to the SRC faster than a 911 response, then yeah they could go ahead and transport.

(I)(B)(6) disallows paramedics from accepting orders from a base hospital, however this could be handled in two ways.

1. Base hospital contact. We have a physician confirmed STEMI, can we go to a STEMI center?

2. Base hospital contact (I believe it would be required anyways). Physician wants to transfer a STEMI patient to a STEMI center (initial destination), patient has chest pain, do you want us to divert. (covered under section (I)(B)(4) ).

IFT paramedics can accept orders from a base hospital, they cannot accept orders from the sending/transferring physician. However, I agree that either of these two suggestions would most likely work. I say "most likely" because given my experiences making base contact as an IFT paramedic, a good deal of time would be wasted explaining the situation to the MICN (e.g. who I am, why 911 wasn't called to begin with, whether I'm an ALS unit, why I'm calling for orders rather than following SOPs or sending physician orders...).

 

[JPINFV]

IFT paramedics can accept orders from a base hospital, they cannot accept orders from the sending/transferring physician.

Opps... that's what I meant...

IFT paramedics can accept orders from a base hospital, they cannot accept orders from the sending/transferring physician. However, I agree that either of these two suggestions would most likely work. I say "most likely" because given my experiences making base contact as an IFT paramedic, a good deal of time would be wasted explaining the situation to the MICN (e.g. who I am, why 911 wasn't called to begin with, whether I'm an ALS unit, why I'm calling for orders rather than following SOPs or sending physician orders...).

"Are you refusing to give me, an ALS ambulance, base hospital instructions in accordance with LACo LEMSA protocol? Yes? Ok, Unit 75 clear." Submit official complaint to LACo LEMSA about MICN refusing to give direction. Do not pass go, do not collect $200.

If the MICN doesn't understand EMS protocol, then the MICN does not need to be anywhere near the radio.

 

[Aidey]

I agree with having the clinic doc talk to the base hospital doc in this situation.

In general this system seems like the perfect place to have the capability to transmit 12-leads to the base hospital. That way in these situations the base physician can look at the 12 lead themselves.

 

[thegreypilgrim]

"Are you refusing to give me, an ALS ambulance, base hospital instructions in accordance with LACo LEMSA protocol? Yes? Ok, Unit 75 clear." Submit official complaint to LACo LEMSA about MICN refusing to give direction. Do not pass go, do not collect $200.

If the MICN doesn't understand EMS protocol, then the MICN does not need to be anywhere near the radio.

Haha, believe me I would love to do something like that, and I agree if they don't understand the way the system works they have no business answering calls. The problem is, I don't think much is done in the way of MICN training to include direction of IFT units, and after having sat in and observed a Prehospital Advisory Committee meeting at LACoEMSA it doesn't seem like it's very high on the priority list.

Again, this wasn't my call. I was on another call at that facility when this happened, and am just relating my experiences with making base contact as a private IFT medic.

 

[thegreypilgrim]

In general this system seems like the perfect place to have the capability to transmit 12-leads to the base hospital. That way in these situations the base physician can look at the 12 lead themselves.

Some ALS units seem to have this capability here. When I was a medic intern, the FD station I was at had a modem equipped with their monitor for transmitting 12-leads, but there was only a link established with one hospital. I had to test it every morning so it worked...it just was never used.

 

[alphatrauma]

In general this system seems like the perfect place to have the capability to transmit 12-leads to the base hospital. That way in these situations the base physician can look at the 12 lead themselves.

One of the ERs I used to work in tried this very thing... FAIL

Either the sending unit was screwed, or the receiving device was malfunctioning. Too much slip between the cup and the lip.

 

[Veneficus]

If the provider can't actually interpret an EKG and make a transportation decision based on their judgement does anyone really think getting them to efficently use 21st century data transfer devices is going to be easier?