Duty to Act, Abandonment, and a CCT Pt on board

[LACoGurneyjockey]

While returning a ventilator dependant patient with an RT we witnessed a traffic collision, rear end at about 20-30mph. Stopped, put on my lights, and found one driver was crying inconsolably and clutching her head, other driver uninjured. Called local FD and went back for a collar. At this time the RT stepped out and said we need to leave. He said if anyone crashes into us he'd be at fault and our patient is too critical.
Now this pt is transported 3 times a week on a ventilator for hemodialysis, and at the time he was stable. If I had been alone with my partner I'd have left him in the back with a stable pt and rendered care until FD arrives. But since the RT demanded we leave, I got back in and drove away, instructing the drivers to stay in their cars and that fire dept was on the way.
I know with a paramedic he is in charge of the unit and I'd follow his direction without question, but is this also the case with a Respiratory Therapist, who is more medically knowledgeable though not necessarily in prehospital trauma and scene safety?
Did I abandon this patient? Should I have disregarded the RT and waited for Fire? The only reason I left was because the RT demanded we do so, and I was under the impression he is the most medically senior crew member, and therefor in charge of the unit.
Does having a Ventilator dependant patient on board trump the possible head injury and C spine.
Basically, what would you do in this situation?

 

[Medic Tim]

While returning a ventilator dependant patient with an RT we witnessed a traffic collision, rear end at about 20-30mph. Stopped, put on my lights, and found one driver was crying inconsolably and clutching her head, other driver uninjured. Called local FD and went back for a collar. At this time the RT stepped out and said we need to leave. He said if anyone crashes into us he'd be at fault and our patient is too critical.
Now this pt is transported 3 times a week on a ventilator for hemodialysis, and at the time he was stable. If I had been alone with my partner I'd have left him in the back with a stable pt and rendered care until FD arrives. But since the RT demanded we leave, I got back in and drove away, instructing the drivers to stay in their cars and that fire dept was on the way.
I know with a paramedic he is in charge of the unit and I'd follow his direction without question, but is this also the case with a Respiratory Therapist, who is more medically knowledgeable though not necessarily in prehospital trauma and scene safety?
Did I abandon this patient? Should I have disregarded the RT and waited for Fire? The only reason I left was because the RT demanded we do so, and I was under the impression he is the most medically senior crew member, and therefor in charge of the unit.
Does having a Ventilator dependant patient on board trump the possible head injury and C spine.
Basically, what would you do in this situation?

Did you consult your partner/rt before stopping? If not you should have . Having a pt on board means they are your priority. If they are stable then by all means stop and help if you can.

In this situation I would have called it in and let them know help was on the way and that you couldn't stay because you already had a pt.

 

[usalsfyre]

If had done this to me it wouldn't have been pretty. Your duty to act (in most places) is to call in the Authority Having Jurisdiction. Your obligation is to the patient you have in your care, not you getting to play Ricky Rescue.

 

[Akulahawk]

Exactly. The patient that is on-board is your priority. Your duty and obligation is to your patient. In a case like this one, your duty and obligation is to call it in to the appropriate jurisdiction and arrange for help. That's it. The call goes something like this:

"Hello, this is akulahawk on Medic 123, Snowball ambulance company, calling in a 2 vehicle collision in the number 5 lane of highway 666 about 1/2 mile north of the Hades off-ramp. Unknown if there are injuries, I'm unable to stop because I have a ventilator patient on board."

Done.

Just make sure that you're calling a recorded dispatch line...

 

[Pkreilley]

The issue here is that you stopped in the first place. Once you initiated care, you're responsible for them too.

 

[Clipper1]

Now this pt is transported 3 times a week on a ventilator for hemodialysis, and at the time he was stable.

Define stable. A 3x/week dialysis patient who is vent dependent is a train wreck of organs all just waiting for their chance to have the slightest thing push them over the edge.

What type of ventilator was the RT using and how much O2 was left in your tanks? How was the HR and BP trending s/p dialysis? It is stressing for them to spend at least 4 hours hooked up to a dialysis machine. I don't blame this RT for wanting to get this patient back to the LTC facility and off an uncomfortable ambulance stretcher especially when the EMTs don't seem to consider the patient they do have a responsibility for or know their policy about transporting ventilator patients.

As others have said, call it in and tell the people help is on the way. Hopefully the RT documented this incident very well.

 

[Tigger]

One would hope a CCT truck doing vent transports has enough O2 onboard to make it through an unplanned delay. Not saying that I agree with the OP's actions (I don't), however there are other causes of delay that need to be accounted for during such transfers and planned for appropriately.

 

[LACoGurneyjockey]

Thanks for all the replies, I guess I should have just called it in and kept going. O2 levels were beyond adequate, and the patients vitals were good, not in any apparent distress. My thinking was that if the patient was not critical to stop and render care while the attendant remains with the patient in the back. My mistake was assuming this patient I transport on a semi regular basis was stable based on that he was in the same condition as usual, perpetually sick and dying.

 

[Clipper1]

One would hope a CCT truck doing vent transports has enough O2 onboard to make it through an unplanned delay. Not saying that I agree with the OP's actions (I don't), however there are other causes of delay that need to be accounted for during such transfers and planned for

CCT trucks in CA might also be a BLS truck called to transport a team. Usuallu it is one RN and 2 EMTs.

When the EMT is starting to take equipment from th ambulance and treat pts on scene, the RT would have a reason to be concerned especially if the EMT did not communicate his intentions.

With some of the ambulances, it is the luck of the draw for their condition. If you want one in good condition and lots of O2 you might have to wait. Some will calculate they have just enough and try to get by. Some hospitals purchase their own ambulance. The hospitals also hired their own EMTs and trained them for consistency so they would know their responsibilities to the patient.

 

[Tigger]

CCT trucks in CA might also be a BLS truck called to transport a team. Usuallu it is one RN and 2 EMTs.

When the EMT is starting to take equipment from th ambulance and treat pts on scene, the RT would have a reason to be concerned especially if the EMT did not communicate his intentions.

With some of the ambulances, it is the luck of the draw for their condition. If you want one in good condition and lots of O2 you might have to wait. Some will calculate they have just enough and try to get by. Some hospitals purchase their own ambulance. The hospitals also hired their own EMTs and trained them for consistency so they would know their responsibilities to the patient.

That is a fairly foolish decision by that provider if that is the chosen course of action.

 

[Clipper1]

That is a fairly foolish decision by that provider if that is the chosen course of action.

True. In a perfect world all ambulances would be big, shiny, very well stocked and do only one of these calls once a year. Unfortunately in some places ambulances will run these calls back to back all day because of the regulations and classifications placed on LTC facilities by the state and CMS. You get used to it and make do with what you get or try to carry as much as you can on your own person which is why many specialty teams need very little or expect very little from the ambulance except reliable transport. However when even the transport is delayed because of a distraction which should not have deviated from the first patient, a trust or contract can also be broken. This is why I suggest reading the policy and knowing what your responsibilities are when providing a service to the patient even if you hate dialysis calls or believe they are just perpetually sick and dying (words from LACoGurneyJockey). In an area which is highly competitive for transport contracts, it wouldn't take much to lose that contract and it could mean the loss of a job for you and several others.

If the RT accepted the patient knowing the O2 might just get them back to the LTC facility and the truck go stuck in traffic, then it is on the RT. It may also have been his 6th dialysis patient which means 12 transports but still no excuse to run out of O2 even with a battle from the ambulance company. If the RT allowed the EMTs to stop for a long period of time to care for ANOTHER patient, it is also on the RT. If the RT reminded them of the responsibility to the patient on board then it is on the EMT and ambulance service and also the RT. The RT or RN on these transports do know they will have to be accountable which includes to the state licensing board if something happens to that patient especially with CMS. If no complaint is filed by the RT or RN then the only thing that might happen to the EMT is some negative remarks on this forum. If the RT allowed this EMT to get out of the ambulance to initiate care on the MVC patients, then it is on the RT and he should face some penalties. If something negative had happened to the patient on board while the truck was stopped, he could expect his license to be suspended while there is an investigation.

 

[LACoGurneyjockey]

This is why I suggest reading the policy and knowing what your responsibilities are when providing a service to the patient even if you hate dialysis calls or believe they are just perpetually sick and dying (words from LACoGurneyJockey).

So the ventilator dependant patient in renal failure with a GCS of 4 is NOT perpetually sick and dying?

 

[Clipper1]

So the ventilator dependant patient in renal failure with a GCS of 4 is NOT perpetually sick and dying?

Yes and that makes them very brittle and even more reason to not stop this transport. It doesn't take much for them to go over the edge to dying and is why many in LT care have a problem with the regulations imposed on these facilities for the services they are allowed to offer without the need for transport but that is another discussion for a different forum. Dialysis and routine transports have gotten a bad rep amongst some EMTs to where you feel they are not to be treated the same as another CCT patient.

 

[LACoGurneyjockey]

It's not that I treated that patient any different than every other patient, I care for them as best I can. But at the same time I have a moral problem keeping someone physically alive with a machine while they are mentally no longer alive, and have no real chance of progressing anywhere but to die.
I realize I should have called it in and kept going, and that's exactly the kind of answer I came here looking for. But don't assume I care for my patients any less simply because they smell bad and don't talk to me...

 

[Clipper1]

It's not that I treated that patient any different than every other patient, I care for them as best I can. But at the same time I have a moral problem keeping someone physically alive with a machine while they are mentally no longer alive, and have no real chance of progressing anywhere but to die. ...

You decide patient care by your own moral beliefs?

When working in health care you can not allow your own personal beliefs get in the way and cloud you judgment for providing care. As an EMT, if this patient is still a full code, you work them. If this patient's facility has contracted with your company to move this patient from point A to point B, you do it. You do not have the authority to decide who lives and dies. Many of us will probably agree about the quality of life for this patient but is it not our decision to determine when he dies or allow it to interfere with the job.

I realize I should have called it in and kept going, and that's exactly the kind of answer I came here looking for. But don't assume I care for my patients any less simply because they smell bad and don't talk to me...

I didn't say anything about their smell. My statements were about a brittle vent dependent dialysis patient. Your statement about your moral problem in the previous paragraph and your actions on this call explain this so I don't have to assume.

 

[CodeBru1984]

I wouldn't have stopped to assist at the scene of an MVA with a vent dependent patient on board. Much like the general consensus here, I too would have radioed it in to dispatch and advised the parties involved that additional help was on the way.

 

[LACoGurneyjockey]

You decide patient care by your own moral beliefs?

When working in health care you can not allow your own personal beliefs get in the way and cloud you judgment for providing care. As an EMT, if this patient is still a full code, you work them. If this patient's facility has contracted with your company to move this patient from point A to point B, you do it. You do not have the authority to decide who lives and dies. Many of us will probably agree about the quality of life for this patient but is it not our decision to determine when he dies or allow it to interfere with the job.





I didn't say anything about their smell. My statements were about a brittle vent dependent dialysis patient. Your statement about your moral problem in the previous paragraph and your actions on this call explain this so I don't have to assume.

I explicitly said I don't treat this patient any different than every other patient and I cared for him as best I could. I don't let my moral beliefs dictate my patient care. At no point did I say anything about deciding who lives and who dies. I was making light at the patients smell, not using it as a justification for lower quality of care.

 

[Akulahawk]

I'm going on a bit of a rant here...

Thanks for all the replies, I guess I should have just called it in and kept going. O2 levels were beyond adequate, and the patients vitals were good, not in any apparent distress. My thinking was that if the patient was not critical to stop and render care while the attendant remains with the patient in the back. My mistake was assuming this patient I transport on a semi regular basis was stable based on that he was in the same condition as usual, perpetually sick and dying.

It's not that I treated that patient any different than every other patient, I care for them as best I can. But at the same time I have a moral problem keeping someone physically alive with a machine while they are mentally no longer alive, and have no real chance of progressing anywhere but to die.
I realize I should have called it in and kept going, and that's exactly the kind of answer I came here looking for. But don't assume I care for my patients any less simply because they smell bad and don't talk to me...

I explicitly said I don't treat this patient any different than every other patient and I cared for him as best I could. I don't let my moral beliefs dictate my patient care. At no point did I say anything about deciding who lives and who dies. I was making light at the patients smell, not using it as a justification for lower quality of care.

Yet you decided to stop and render aid... while transporting a ventilator dependent, renal failure patient. You assumed that this patient was stable. You assumed that this same patient, with a GCS of 4, essentially has no future. I'm going to assume that your patient was full code... so now you've learned that patients like this are very brittle. What would have happened if your patient crumped while you were outside the ambulance? What if your ambulance ran out of fuel or oxygen or another vehicle rear-ended it because you stopped in traffic? While you may believe that it's not moral to allow machine-dependent people to live, while you are on the job as a healthcare provider, you may not follow that belief. Someone else has made that decision for you, and that person very well could be the patient you're transporting. You may not project your own morals onto people. The moral thing to do would have been to protect your own crew and your patient from hazards that you placed them in by deciding to stop at the scene of a wreck unnecessarily.

 

[LACoGurneyjockey]

I realize my mistake, and I would handle the situation differently as of now. I was naive to the condition of the patient, correlating stability with 'normal for patient'. But I did not stop because I was ok with causing my patient harm. I stopped because I falsely believed my current patients outcome would not be affected by rendering care at the mvc.

 

[Akulahawk]

I realize my mistake, and I would handle the situation differently as of now. I was naive to the condition of the patient, correlating stability with 'normal for patient'. But I did not stop because I was ok with causing my patient harm. I stopped because I falsely believed my current patients outcome would not be affected by rendering care at the mvc.

From my own perspective, it's not that we're dogpiling on you because we need something to chew on. It's that we see things that you do not yet, and we really want you to broaden your perspective a bit on things. I've never seen people dogpile on someone just for fun. While your patient's outcome may not have changed or been affected by rendering aid, you exposed your unit, your patient, and your crew to hazards that they needn't be exposed to. Sure while driving an ambulance on the freeway is a little hazardous, stopping one on the freeway is even more so. You had a crew and patient in the back, so one good hit and your own crew and patient would probably become part of a crumpled ambulance.

We just want you to realize that often there are more considerations beyond legal ones that play into decisions as to whether you stop and render aid or you continue travel and call it in. Also, you're part of a team. You do not unilaterally make decisions when you're not the team leader. The team leader makes decisions based on many things, often in consultation with the rest of the team.

Now, consider this a good lesson, so now go forth and have yourself some fun.