Ethics Question: BLS Turfing

[RocketMedic]

Is it ethical to leave a patient in pain or nauseated or who could otherwise benefit from paramedic-level interventions to be attended and treated to a subordinate scope of practice due to a lack of life-threatening need?

Is it right to have EMT-Basics or Intermediates attend patients who could benefit from paramedic-level interventions like pain management, antiemetics or IV fluid?

 

[DesertMedic66]

IMO no. Pain management is one of the very few things that can make a huge impact on patient care and patient comfort.

 

[46Young]

The patient that is nauseated and/or in pain should be treated by a paramedic, every time, if they request pharmacological intervention, after being offered these interventions.

Having said that, in a tiered system, sick calls, MVA's, falls, and injuries should be dispatched BLS only. If the BLS onscene determine the need for pain management or anti-emetics, and the patient agrees to/requests these meds, then a request for ALS is indicated.

What I find inappropriate is when BLS request ALS to get out of a transport, reasoning that the patient may possibly need meds at some point. This need should be confirmed prior to requesting ALS. Offer the meds to the patient and get their consent, or otherwise it should be an obvious case where the patient cannot be moved without significant pain.

Really, in any "all-ALS" system, the situations where we can make a real difference is in the area of pain management and comfort care. Anyone who has done this for more than a minute knows that most of the calls in an all-ALS system are typically V.O.M.I.T calls - Vitals, Oxygen, Monitor, IV, Transport. Medics that willingly withhold pain management whenever possible are barbaric, and probably lazy, since they don't want to be hassled with restock procedures, and mandatory PCR QA/QI for narcotics usage (in some systems).

 

[medicsb]

In a system with limited resources, tying up ALS for anti-emetics or pain management may not be possible for every person that is puking or in pain. Up to a point, the nauseous and the "in pain" need to "walk it off". It's silly to go handing out fentanyl or morphine to everyone who says they're in pain (or asks for "something" for the pain). But, I agree, it can be quite cruel to not treat when you have the means. Where does one draw the line? I'm not really sure, but I know it needs to be drawn.

Again, we're talking about setting where ALS is a limited resource (e.g. the county of 950K with 11 medic units at peak hours). In such circumstances, I'd rather ALS be available for chest pains, respiratory emergencies, unconscious patients, etc. However, this is not to say that ALS for pain management only should never be done, just that one should be conservative to a certain extent.

Ultimately, I don't see any reason why an AEMT/EMT-I should not be allowed to give zofran ODT, motrin, or even IN fentanyl.

 

[triemal04]

The patient that is nauseated and/or in pain should be treated by a paramedic, every time, if they request pharmacological intervention, after being offered these interventions.

No. In fact, absolutely not. You don't give people medications because they ask for them, you give them because there is a need for them. If there is no need for them, then no offer of their administration should be made.

Really, in any "all-ALS" system, the situations where we can make a real difference is in the area of pain management and comfort care. Anyone who has done this for more than a minute knows that most of the calls in an all-ALS system are typically V.O.M.I.T calls - Vitals, Oxygen, Monitor, IV, Transport. Medics that willingly withhold pain management whenever possible are barbaric, and probably lazy, since they don't want to be hassled with restock procedures, and mandatory PCR QA/QI for narcotics usage (in some systems).

If you (general "you") work in an all ALS system and the patient has a "need," even if it is very minimal need, for something you can do then absolutely, do your job and treat them. That shouldn't take a lot of thinking about.

If on the other hand, you work for a truly tiered system with minimal ALS units and a lot of BLS units, you will have to make the decision about what that patient actually needs right then, versus what they can wait 20-60 minutes for, and what impact, if any, you will have on their current illness, overall mortality, potential length of hospital stay, potential ICU admission. You'll have to base the comfort needs of the patient against the limited resources that are available for more emergent needs.

Then there's people who run in combined ALS/BLS units. Maybe a little bit of a tougher decision; do you make the paramedic take everything because there is some small thing they can do to make the patient more comfortable (even if they weren't that uncomfortable), or do you make the EMT do their job and treat patient's that don't have an immediate need for medications?

We have the ability to give a lot of medications and treat a lot of different things; this needs to be tempered with the understanding that just because we can, doesn't mean that we always need to, or should.

 

[Rialaigh]

You asked if it is ethical to withhold from those that are not in "life threatening need". I say no it is not ethical. However I think it is perfectly ethical to withhold from those not having an "emergency"

From an ethics standpoint it is absolutely okay to withhold ALL treatment from patients that have been determined to not have an emergency situation. This includes transport. From a legal standpoint obviously things are quite different.

I define an emergency situation as something that will not resolve without medical intervention and could worsen greatly within 48 hours or leave permanent disability.

 

[sir.shocksalot]

At what point do people take the pt's subjective experience into account? Pain, nausea, and discomfort are subjective experiences that may or may not have objective findings. At what point can anyone ethically say that someone is not in pain or that their pain is not sufficient enough to warrant treatment?

I understand that system abusers exist and providing them with treatments and services that they abuse negatively affects those that might need those services. Does anyone have systems in place to track and warn providers when they are running on a system abuser or drug seeker? If not, do you simply rely on your gut? If so, how many people have gone without treatment because their behavior made you believe they were seeking?

The only ethical thing to do is to assume that anyone who has called with a complaint warrants treatment. If an antiemetic or analgesic is indicated then it should be offered. If the patient doesn't want the medication then no, a paramedic doesn't need to attend provided no other ALS treatment is indicated. I'd rather treat 100 seekers than miss one person who is legitimately in pain or discomfort. If that means I'm stuck attending on every patient... Well, at least I'm earning the $8 extra an hour over my EMT.

 

[Rialaigh]

At what point do people take the pt's subjective experience into account? Pain, nausea, and discomfort are subjective experiences that may or may not have objective findings. At what point can anyone ethically say that someone is not in pain or that their pain is not sufficient enough to warrant treatment?

I understand that system abusers exist and providing them with treatments and services that they abuse negatively affects those that might need those services. Does anyone have systems in place to track and warn providers when they are running on a system abuser or drug seeker? If not, do you simply rely on your gut? If so, how many people have gone without treatment because their behavior made you believe they were seeking?

The only ethical thing to do is to assume that anyone who has called with a complaint warrants treatment. If an antiemetic or analgesic is indicated then it should be offered. If the patient doesn't want the medication then no, a paramedic doesn't need to attend provided no other ALS treatment is indicated. I'd rather treat 100 seekers than miss one person who is legitimately in pain or discomfort. If that means I'm stuck attending on every patient... Well, at least I'm earning the $8 extra an hour over my EMT.

To comment on your bold statement, I have never withheld LIFE OR LIMB SAVING TREATMENT. I don't think it's fair to group all treatments we have available to us into the same group. I am surely not going to judge you for not medicating a patient that was having legitimate pain. Frankly if we operate under an "emergency medical service" mindset it's not our role.


When is the cost to high for you? 1000 seekers to one legit person? A million? it is absurd to have an all or nothing attitude about treating patients like this.

It depends on what is causing the pain for me, not as much how much pain you are in although that will still factor some.

 

[Carlos Danger]

In a system with limited resources, tying up ALS for anti-emetics or pain management may not be possible for every person that is puking or in pain. Up to a point, the nauseous and the "in pain" need to "walk it off". It's silly to go handing out fentanyl or morphine to everyone who says they're in pain (or asks for "something" for the pain). But, I agree, it can be quite cruel to not treat when you have the means. Where does one draw the line? I'm not really sure, but I know it needs to be drawn.

Again, we're talking about setting where ALS is a limited resource (e.g. the county of 950K with 11 medic units at peak hours). In such circumstances, I'd rather ALS be available for chest pains, respiratory emergencies, unconscious patients, etc. However, this is not to say that ALS for pain management only should never be done, just that one should be conservative to a certain extent.

Ultimately, I don't see any reason why an AEMT/EMT-I should not be allowed to give zofran ODT, motrin, or even IN fentanyl.

This.

 

[jrm818]

To comment on your bold statement, I have never withheld LIFE OR LIMB SAVING TREATMENT. I don't think it's fair to group all treatments we have available to us into the same group. I am surely not going to judge you for not medicating a patient that was having legitimate pain. Frankly if we operate under an "emergency medical service" mindset it's not our role.


When is the cost to high for you? 1000 seekers to one legit person? A million? it is absurd to have an all or nothing attitude about treating patients like this.

It depends on what is causing the pain for me, not as much how much pain you are in although that will still factor some.

While I think we can all understand the thought to restrict EMS to purely life or limb threatening problems, the role of EMS seems to have morphed in the current system. truly life threatening problems don't seem to be a very large percentage of EMS call volume and, frankly, EMS treatment is impotent when confronted with many life-threatening problems and basic transport is probably most important). Similarly, it is extremely difficult to determine a priori what conditions have the possibility to deteriorate and constitute emergencies...the data that I am aware of actually suggest that emergency department mis-utilization isn't as big a problem as we think, and this may be true of EMS as well.

Medical attitudes to treating pain have shifted somewhat (or gone back to basics: treating pain has always been a huge part of medicine, including emergency care), and its a place that EMS has a chance to demonstrate its added value to patients. Many EMS providers would be out of jobs were we to truly restrict EMS to life-saving care only (and since transportation to an ED is an adequate treatment even for many life-threatening conditions perhaps paramedics would not be quite as needed in areas near to a hospital.

While it may be ethical to have a system that refuses to transport patients with non-life threatening conditions, if you are going to transport a patient and thus be unavailable for other calls anyways, what justification is there for refusing to manage your patients complaint to the best of your ability, including their complaint of pain? Are we too good for them?

 

[DrankTheKoolaid]

No. In fact, absolutely not. You don't give people medications because they ask for them, you give them because there is a need for them. If there is no need for them, then no offer of their administration should be made.



If you (general "you") work in an all ALS system and the patient has a "need," even if it is very minimal need, for something you can do then absolutely, do your job and treat them. That shouldn't take a lot of thinking about.



If on the other hand, you work for a truly tiered system with minimal ALS units and a lot of BLS units, you will have to make the decision about what that patient actually needs right then, versus what they can wait 20-60 minutes for, and what impact, if any, you will have on their current illness, overall mortality, potential length of hospital stay, potential ICU admission. You'll have to base the comfort needs of the patient against the limited resources that are available for more emergent needs.



Then there's people who run in combined ALS/BLS units. Maybe a little bit of a tougher decision; do you make the paramedic take everything because there is some small thing they can do to make the patient more comfortable (even if they weren't that uncomfortable), or do you make the EMT do their job and treat patient's that don't have an immediate need for medications?



We have the ability to give a lot of medications and treat a lot of different things; this needs to be tempered with the understanding that just because we can, doesn't mean that we always need to, or should.

In regards to the ALS/BLS crews and the Medic turfing it to their BLS partner. I'm going to make an assumption here that the company bills like every company I'm aware of in California. Even if the BLS partner takes the patient as long as a Paramedic is on board that patient is being charged the ALS1 level rate. So why would the Parmedic not take the call since the patient is being billed the same either way.

That I do find unethical. If the patient is paying for paramedic level care why is it not being provided, even if it is baby sitting.

 

[mycrofft]

Let me see if I got it.

A paramedic is not sent, or refuses to attend a patient, since the call is not "life threatening"? And measures to stop a patient's severe distress are not in the scope of the responder sent?

1. If the Paramedic responds but on arrival refuses to attend despite dispatch and it's up to a paramedic to ameliorate pain and suffering, the paramedic is wrong. Ditto if the paramedic refuses to go at all.

2. If the dispatch was for an EMT instead of a paramedic because the dispatcher thought it didn't require a paramedic, the dispatcher is triaging by phone, which is damned risky and probably the dispatcher is not a qualified medical person anyway.

3. If it was a triage question where the presence of the (only?) paramedic at your case endangered someone else (a definite case, not "there might be an emergency") by their absence, then they are right.
IMHO.

 

[Rialaigh]

While I think we can all understand the thought to restrict EMS to purely life or limb threatening problems, the role of EMS seems to have morphed in the current system. truly life threatening problems don't seem to be a very large percentage of EMS call volume and, frankly, EMS treatment is impotent when confronted with many life-threatening problems and basic transport is probably most important). Similarly, it is extremely difficult to determine a priori what conditions have the possibility to deteriorate and constitute emergencies...the data that I am aware of actually suggest that emergency department mis-utilization isn't as big a problem as we think, and this may be true of EMS as well.

Medical attitudes to treating pain have shifted somewhat (or gone back to basics: treating pain has always been a huge part of medicine, including emergency care), and its a place that EMS has a chance to demonstrate its added value to patients. Many EMS providers would be out of jobs were we to truly restrict EMS to life-saving care only (and since transportation to an ED is an adequate treatment even for many life-threatening conditions perhaps paramedics would not be quite as needed in areas near to a hospital.

While it may be ethical to have a system that refuses to transport patients with non-life threatening conditions, if you are going to transport a patient and thus be unavailable for other calls anyways, what justification is there for refusing to manage your patients complaint to the best of your ability, including their complaint of pain? Are we too good for them?

The problem is we are responding to a vast majority of non emergency calls while trying to still act like a emergency system. The issue is one that I could write pages on and it filters down to everything from response times to pain management and everything between.

As far as the current system I work in, you have to have online medical control for pain meds, period. The hospital we call has 2-3 physicians on at a time (generally 2) and is a 20 bed main ER that they are responsible for with a 6 bed fast track and then we utilize up to 10 "hallway stretchers) and frequently patient volume is over 50 in the department for 8-12 hours of the day. I am not going to take up a physicians time at this facility for someone with non descript unidentifiable pain with stable vitals that I think will likely end up going to triage (and thus the waiting room) anyway at this ER.

When protocols are advanced in this state and the system is changed to reflect the nature of the calls we run, AND, we are given more options for pain medication then I will be more than happy to try and medicate everyone who has a complaint of pain.


Quite frankly my pain management options here are morphine, and fent. That is it. If I had some non narcotic options I would be very happy as would the patients.

 

[triemal04]

I'm going to make an assumption here that the company bills like every company I'm aware of in California. Even if the BLS partner takes the patient as long as a Paramedic is on board that patient is being charged the ALS1 level rate. So why would the Parmedic not take the call since the patient is being billed the same either way.

That I do find unethical. If the patient is paying for paramedic level care why is it not being provided, even if it is baby sitting.

Maybe that's part of the reason so many places in California have terrible care and are being investigated by the feds; what you just referenced is called insurance fraud.

 

[DrankTheKoolaid]

Actually that is by Medicare rules, well at least that is how it was explained to us by our billing company

 

[triemal04]

Actually that is by Medicare rules, well at least that is how it was explained to us by our billing company

To be an ALS1 rate the paramedic has to at minimum assess the patient and perform an "ALS intervention."

So yes, technically they could do an assessment, run an ekg, turn the patient over to the EMT and bill it as an ALS1 call. I think.

But if they did nothing, and just were there, that couldn't be billed as ALS1.

 

[DrankTheKoolaid]

Right. This is strictly 911 I'm talking about and everyone is assessed by the Medic before being given to a BLS partner

 

[triemal04]

Right. This is strictly 911 I'm talking about and everyone is assessed by the Medic before being given to a BLS partner

Not neccasarily. When I work with an EMT I don't talk with every patient or do something; if it's a call that they may be taking there is no reason that they can't do their own assessment and I'll listen in and decide whether or not to take over. Even if I ask a couple of questions that would still be insurance fraud.

Good god, no wonder so many EMT's are incompetant; apparently they aren't allowed to assess a patient if that person called 911. :wacko:

 

[DrankTheKoolaid]

No that's not the case, in the system I'm talking about I always tried to encourage partners to start off every patient contact and give me the signal when I needed to take over. Obviously I'm doing my own assessment while they are doing this also. And the majority of the paramedics there had the same mindset. We always encourage further education and stepping out of there comfort zones to encourage them

 

[NomadicMedic]

The problem is we are responding to a vast majority of non emergency calls while trying to still act like a emergency system. The issue is one that I could write pages on and it filters down to everything from response times to pain management and everything between.

As far as the current system I work in, you have to have online medical control for pain meds, period. The hospital we call has 2-3 physicians on at a time (generally 2) and is a 20 bed main ER that they are responsible for with a 6 bed fast track and then we utilize up to 10 "hallway stretchers) and frequently patient volume is over 50 in the department for 8-12 hours of the day. I am not going to take up a physicians time at this facility for someone with non descript unidentifiable pain with stable vitals that I think will likely end up going to triage (and thus the waiting room) anyway at this ER.

When protocols are advanced in this state and the system is changed to reflect the nature of the calls we run, AND, we are given more options for pain medication then I will be more than happy to try and medicate everyone who has a complaint of pain.


Quite frankly my pain management options here are morphine, and fent. That is it. If I had some non narcotic options I would be very happy as would the patients.

The fact that you don't want to bother the doc to get orders to medicate a patient that may need it is beyond disturbing.

Here's a pro tip. BOTHER THE DOC.