bls transport refusing a patient

[MusicMedic]

I think you did the right thing, If ALS is closer, wait for them.. because if the Patient crashes En Route, theres not many interventions BLS can do.. and honestly he really did not sound stable at all..

I had a similar Call the other day, (i work for a transport company too)

Nursing Home calls Dispatch, Dispatch Calls us for CVA... we show up, patients Chief Complaint of Crushing Chest pain radiating down her left arm 6 Hours ago, Paitent is currently not having any pain at all, My partner does a quick Medical Eval, Vital Signs are stable, patient is very stable... we decide not to call ALS because, the patient is stable and the Fire Medics would most likely send it BLS anyways (in Orange County they BLS everything unless its Life-threating), We call our supervisor, she okays it.. We Load her up and take her to an ER, find out she has a Minor Left Branch Infarct.. Now one of the Paragods/Ricky Rescue at our station overheard the call, and started to give us :censored::censored::censored::censored: because we didnt call ALS or go Code on the call, but we both knew he was a jackass and the patent was stable

but you have to love IFT Company Drama!!

 

[Akulahawk]

Nope... never had a problem at my old place with requesting paramedics. Of course requesting paramedics was easy. Pick up the phone, call 911, advise 911 dispatcher that this was a BLS crew. I never advised the nursing staff that I was requesting paramedics until I was on the phone with the 911 operator.

Something to remember, though. If transport time to the closest hospital is less than the paramedic response time, then just transport unless you don't have enough providers on scene to provide care (i.e. cardiac arrest).

I've seen some SNF's do some whacked things over the years...
Where I used to work about 10 years ago, local protocol authorized exactly this. At the time, the "clock" started when the EMT made patient contact. The SNF folks KNEW this as well, so they'd call BLS for (quite literally) everything short of a full arrest, with a full code patient. Since many of the SNF's were close to a hospital, they knew that a BLS crew could get the patient to the ED faster than 911 could. They also knew that the bill would be much lower...

A few years later, the county changed to requiring an interval of 10 minutes from arrival on scene to arrival at the ED, if the patient was unstable. The crew was to call 911/county comm and determine if the ETA for ALS was quicker than their own transport ETA. Since the arrival time to ED ETA time would almost ALWAYS be more than 10 minutes... The SNF's "learned" and stopped calling BLS for all the stuff they used to and started calling 911. Surprises happened from time to time, but those were usually en-route.

Eventually, ALS-IFT became authorized and the SNF's started calling for that instead for those patients that were unstable and didn't want to have to have another 911 call on their books...

 

[Shishkabob]

Keep in mind, just because they are "nurses" doesn't mean they can do better for your patient than you can.



CPR on the xiphoid process anyone? :glare:




You'll gain experience, and with that you'll know what will be better for your patient then you think now. And if something totally throws you through a loop, grab your phone and call dispatch.

 

[8jimi8]

BTW,

most RNs at a SNF are usually in supervisory positions i.e. they have 60 patient's they are responsible for.

let's be careful about bashing other medical professionals.

Even still... an LVN has more education than a basic or an intermediate.

So let's play nice, eh? I can give you just as many examples of sub-par EMTs.

 

[firecoins]

I don't know how your system works.

BLS IFT don't refuse calls per se. They call ALS and load the patient in their rig. We go on board their rig and transport the patient in the BLS rig. The ALS rig is driven by the other medic.

 

[Shishkabob]

I stand by what I said:

Just because they have the word "nurse" in their title does not instantly make them better for your patient than you are.

From the moment you get dispatched, that patient is yours. If you deem something is or is not needed (preferably IS at a basic level) then it is your responsibility to handle the need. If a nurse disagrees, she can go through the proper channels.

 

[xsullyx]

have two issues with that linus.

first being that, as a higher level of care provider, a nurse is better than a basic. regardless of dedication to the job or attitudes or egos their education makes them better... or should but most importabtly does in the eyes of the state.

consider this: if you have come upon a cardiac arrest while at the store or sumthing and there is a first responder and a bystandetlr doing cpr. you can come in and take the scene as a higher care provider. i think the same applies to this situation just in a less emergent fashion.

second, this is not 911 this transport. emergent transport but transport nonethe less. he is already in the care of a higher level provider so the patient is most certainly not mine upon dispatch.

if i had taken the patient and not called als just to get him to the hospital, and the guy crapped out enroute, i really believe id be standing in front of the regional ems council explaining why i didnt call 911 for als or even have any business taking care from the nurse in the first place as a basic

 

[8jimi8]

The point i was making was not about being a "better" provider. The point i was making was that we shouldn't make sweeping generalizations about such things as, "Nurses don 't know how to do CPR." I understand that Linuss had a run-in with some "nurses" doing cpr in the incorrect position. Again, that is the provider that you encountered, not all of us.

Especially when you run into a situation where the provider is an LVN. That is one year of school... Degreed paramedics definitely have more education than an LVN. Especially when you start looking at emergency situations. I can see a Basic having more experience than an LVN when it comes to emergencies. These nurses may not have had the experience to deal with the situation and that may be why they were freaking out when the op wanted to call 911.

I think the OP made the correct decision.

I still denounce any and all sweeping, blanket generalizations where one provider says i'm better than so and so, or all so and so's don't know anything.

Sorry Linuss, you are wrong on this one.

We are all on the same team. Sometimes basics save paramedics, sometimes nurses save doctors and sometimes not even God will save you.

So let's look at the facts and avoid denigrating our teammates, eh?

 

[Shishkabob]

*Sigh*

More education does not always equate better. Anyone who's been in the field a while has seen their share of stupid nurses, AND stupid EMTs and medics. It's on both sides of the fence, and has little correlation to education.

Just because they are a nurse does NOT make them your superior or have control over the scene (dependent upon your local laws and your own protocols).

if i had taken the patient and not called als just to get him to the hospital, and the guy crapped out enroute, i really believe id be standing in front of the regional ems council explaining why i didnt call 911

And where has ANYONE disputed that? But, as has been stated multiple times in this thread, you have to weigh waiting on scene for ALS and initiating rapid transport... DO NOT delay getting your patient to definitive care, and NO, the nurses at the nursing home are not definitive care. They called you because they are no longer able to cope with the patients condition.

Again, you need to do what's in the best interest of your patient, and the best way to do that is follow your protocols and contact med control if you have to.

 

[Shishkabob]

I still denounce any and all sweeping, blanket generalizations where one provider says i'm better than so and so, or all so and so's don't know anything.

Sorry Linuss, you are wrong on this one.

I said, and I quote:

"just because they are "nurses" doesn't mean they can do better for your patient than you can."


Where's the sweeping generalization? I never said all nurses sucked, or most nurses suck, or all EMTs are better then all LVNs. I said don't make assumptions that just because they have nurse in their title does not make them better than you, or that they can only do good and not bad... how is that a wrong rationalization?




You're preaching to the choir of not making generalizations based on certification! I've always called people out on this forum who do something of that nature, so why would I turn around and be a hypocrite?

 

[JPINFV]

have two issues with that linus.

first being that, as a higher level of care provider, a nurse is better than a basic. regardless of dedication to the job or attitudes or egos their education makes them better... or should but most importabtly does in the eyes of the state.

Education isn't nearly as important as the ability to intervene. Now let me clarify that the ability to intervene must be backed up by a proper education, but if I had a choice between a cardiologist fresh out of a fellowship or a PhD who has devoted his life to studying MIs taking me to the cath lab, I'll take the cardiologist even though the PhD is more educated about MIs than the physician. Similarly, an ambulance crew, regardless of basic, paramedic, or anywhere in-between, has one major intervention that is not available to the nursing home staff. The ability to transfer. I would argue that any critical care transport results in a transient decrease in the level and ability to care for the patient (i.e. accepting care from the transfering facility and during the transport), but results in the end in achieving the goal of giving the patient a higher level of care (delivery to a specialty center). As such, outside of only a handful of situations (i.e. cardiac arrest), I can't see any reason why a basic level crew should refuse a patient. Call paramedics? Sure. Transport emergently to the nearest emergency department, rerouting if need be? Sure. Just saying, "Sorry, this patient is too sick to take to the emergency department by us, call someone else"? Never.

Now this is not to say that you shouldn't:
1. Request paramedics.
2. Initiate treatment.
3. Package and engress to the ambulance in preparation of paramedic arrival.
4. Assist paramedics when they arrive, up to and including, transporting with paramedics on board your ambulance.

second, this is not 911 this transport. emergent transport but transport nonethe less. he is already in the care of a higher level provider so the patient is most certainly not mine upon dispatch.

You are on a call originating someplace out in the community (a nursing facility) where the requested termination point of the transport is an emergency department. You are an emergency ambulance in this situation. Saying, "... but... but...but we're not a 911 ambulance" is, in all honestly, a cop out. Do you really think you are that much different than an EMT-B working for a 911 company?

if i had taken the patient and not called als just to get him to the hospital, and the guy crapped out enroute, i really believe id be standing in front of the regional ems council explaining why i didnt call 911 for als or even have any business taking care from the nurse in the first place as a basic

Personally, I'd rather describe how a patient crashed during a short transport to the closest emergency room (which, according to you, was not the case with this patient), than crashed in the back of my ambulance as I sat on scene waiting for the paramedics longer than it would have taken me to get to the emergency room.

 

[Veneficus]

I would argue that any critical care transport results in a transient decrease in the level and ability to care for the patient (i.e. accepting care from the transfering facility and during the transport), but results in the end in achieving the goal of giving the patient a higher level of care (delivery to a specialty center)..

You mean an ancillary provider of some type and a nurse isn't the same level of care as a hospital unit full of specialists?

I'm devastated.

 

[JPINFV]

You mean an ancillary provider of some type and a nurse isn't the same level of care as a hospital unit full of specialists?

I'm devastated.

Only if one of Mary Mundinger's DNPs is the nurse on board the ambulance.

 

[8jimi8]

I said, and I quote:

"just because they are "nurses" doesn't mean they can do better for your patient than you can."


Where's the sweeping generalization? I never said all nurses sucked, or most nurses suck, or all EMTs are better then all LVNs. I said don't make assumptions that just because they have nurse in their title does not make them better than you, or that they can only do good and not bad... how is that a wrong rationalization?




You're preaching to the choir of not making generalizations based on certification! I've always called people out on this forum who do something of that nature, so why would I turn around and be a hypocrite?

sorry dude sometimes i'm retarded

 

[jgmedic]

Education isn't nearly as important as the ability to intervene. Now let me clarify that the ability to intervene must be backed up by a proper education, but if I had a choice between a cardiologist fresh out of a fellowship or a PhD who has devoted his life to studying MIs taking me to the cath lab, I'll take the cardiologist even though the PhD is more educated about MIs than the physician. Similarly, an ambulance crew, regardless of basic, paramedic, or anywhere in-between, has one major intervention that is not available to the nursing home staff. The ability to transfer. I would argue that any critical care transport results in a transient decrease in the level and ability to care for the patient (i.e. accepting care from the transfering facility and during the transport), but results in the end in achieving the goal of giving the patient a higher level of care (delivery to a specialty center). As such, outside of only a handful of situations (i.e. cardiac arrest), I can't see any reason why a basic level crew should refuse a patient. Call paramedics? Sure. Transport emergently to the nearest emergency department, rerouting if need be? Sure. Just saying, "Sorry, this patient is too sick to take to the emergency department by us, call someone else"? Never.

Now this is not to say that you shouldn't:
1. Request paramedics.
2. Initiate treatment.
3. Package and engress to the ambulance in preparation of paramedic arrival.
4. Assist paramedics when they arrive, up to and including, transporting with paramedics on board your ambulance.


You are on a call originating someplace out in the community (a nursing facility) where the requested termination point of the transport is an emergency department. You are an emergency ambulance in this situation. Saying, "... but... but...but we're not a 911 ambulance" is, in all honestly, a cop out. Do you really think you are that much different than an EMT-B working for a 911 company?




Personally, I'd rather describe how a patient crashed during a short transport to the closest emergency room (which, according to you, was not the case with this patient), than crashed in the back of my ambulance as I sat on scene waiting for the paramedics longer than it would have taken me to get to the emergency room.

While in principle I agree JP, having worked behind the Orange Curtain, how many times have RN's and MD's gone about 3 feet up your *** about bringing in an "ALS" patient BLS. Having worked for Care and CRA, I've seen it both ways, I have gotten my *** chewed for bringing in patients and not waiting for medics, and I know tons of other EMT's in the same predicament, that have been told to always wait for medics, and then received another reprimand from supervisors for the same thing. Not saying it's right, but unfortunately, in the back-asswards universe of OCEMS it's what they wanted.

 

[Veneficus]

Only if one of Mary Mundinger's DNPs is the nurse on board the ambulance.

While I have seen many capable NPs (and a few who probably shouldn't be allowed to continue practicing) The DNP program curriculums I have seen are woefully inadequate to equal or replace a physician. It is a low cost alternative for those who cannot afford a doctor.

The idea of “doctor nurse” is faulty. An 8 year nursing degree doesn’t equal the minimum of 11 years of a medical degree with a bunch of “nursing practice” clinicals.

The only advanced nursing curriculum I have seen that I can respect is the CRNA. In the comparisons I have seen, they come the closest in terms of scientific work.

If calling themselves “doctors” stokes their ego, so be it I guess, but to call it equal is just ignorance or hubris.


It must be nice to get recognition for a basic dx.
http://online.wsj.com/public/article_print/SB120710036831882059.html

How astute, she figured out the complication of one of the most common diseases in medicine. Wonder if I could have passed my rheumatology clinical much less garner some praise without such profound knowledge?

"Edwidge Thomas, a doctor of nursing practice, noticed something in her blood test that indicated a form of rheumatic infection linked to her arthritis."

Then she sent the patient to a real doctor. A proud day in nursing history I guess.

"The diagnosis was confirmed when Ms. Gleason was referred to a neurologist, who prescribed medication."

 

[JPINFV]

While in principle I agree JP, having worked behind the Orange Curtain, how many times have RN's and MD's gone about 3 feet up your *** about bringing in an "ALS" patient BLS. Having worked for Care and CRA, I've seen it both ways, I have gotten my *** chewed for bringing in patients and not waiting for medics, and I know tons of other EMT's in the same predicament, that have been told to always wait for medics, and then received another reprimand from supervisors for the same thing. Not saying it's right, but unfortunately, in the back-asswards universe of OCEMS it's what they wanted.

Did it happen to me when I worked for Lynch (on a side note, I worked for Lynch from 2005-2007, which was before Dr. Stratton took over OCEMS and the system actually began writing BLS protocols besides the ETA transport clause)? Sure. At the same time I've had hospital staff completely understand where I'm coming from and why I've done what I've done. Other times I've been yelled at for not calling 911 despite being 1 minute away and only passing a stop sign (I love you too HBMC). Now I've done a few things also. In the end, I have to be able to go home at the end of the shift knowing I provided the best possible care I can. That includes not calling paramedics when my transporting 0.5 miles that consists of a right turn and 2 lefts. I'd rather explain why I transported a patient (who in this case was in a 3rd degree heart block) 2-3 minutes than wait for paramedics on scene. I'd rather explain not calling paramedics for the non-verbal patient that the SNF staff said is "complaining of chest pain" when the nearest hospital is 0.2 miles away on the same side street (The HBMC incident) and any responding FD units would have to pass the hospital on their way to the facility. I am definitely not above having a copy of the transport protocol [PDF. Top of page two. The V/S and reporting requirement were added after I left] with me and providing it to the staff with my PCR and the rest of the patient's package. If bad things happen, I'd much rather stand before my company or county EMS and explain why I transported emergently to the closest ED than sat on my hands waiting for paramedics longer than it would have taken to transport.

If an RN gets mad at me, I don't take it personally. Yes, I know my interventions are very limited and, in many cases, useless for the patient as presented. However it still comes down to the fact that I ultimately can transport and reroute to the nearest hospital. The only times I can think of right now where I can justify requesting paramedics regardless of ETA vs transport time is when I have an extended egress ETA (call early is my motto for requesting paramedics. They can respond while the patient is making his/her way to the ambulance), cardiac arrests, when I need assistance moving the patient, or in a "X hospital or I sign AMA" (assuming unstable patient) case. The hospital staff can whine as much as they want, but I ultimately report to county EMS and my company for the appropriateness of my care and the decisions I make and not to them.


On a side note, I highly advise any EMT-B to keep a copy of uncommonly used, controversial, or generally not well understood protocols in their personal clipboard. I kept a copy of the transport protocol and the DNR protocol (the DNR protocol is very liberal in OC and different than most 'standard' protocols as taught in school). Additionally, I had a printout of the elder abuse procedure, elder abuse reporting form, company incident report form, and a preaddressed, stamped envelope in my backpack. The last thing I want to do is get into an argument with a partner on scene that doesn't know the protocols (yes, in OC we can take a verbal request to "withdraw or withhold resuscitation" from a family member) or trying to figure out how to report abuse on the fly.

 

[ochacon80]

Our owner advised us that there should never be any reason for us to call ALS. He always jaws about how our protocol states that if we are within 5 minutes of any ER its an automatic transport. He doesnt take into consideration what type of condition the Pt is in, or if they need any interventions prior to transport. Truth be told, for most of these owners its all abot the money. Every call that we dont take is money lost in their pockets. Marketers for some private companies are the worst. I know of plenty of BLS companies that make promises to Con Homes that 911/ALS will never be called, if they give said company more calls. It really makes me sick the way a lot of companies here in LA operate.

 

[JPINFV]

Our owner advised us that there should never be any reason for us to call ALS. He always jaws about how our protocol states that if we are within 5 minutes of any ER its an automatic transport. He doesnt take into consideration what type of condition the Pt is in, or if they need any interventions prior to transport.

If the hospital is 5 minutes or less away (which, to be fair, the actual protocol for LACo is time based as well*), what intervention is worth delaying transport for more than 5 to wait on scene for paramedics for outside of a cardiac arrest? Let's say the paramedics respond. 4-6 minute response time is reasonable. The problem is that it's not like they arrive and then just magically whip out the intervention. They're going to take report from you, from the staff, and conduct their own assessment. If, say, the patient needs some sort of IV medication (let's say D50 for hypoglycemia), then they're going to have to start an IV. The patient is still going to have to be packaged and still going to be transported. Alternatively, in that 4-6 minute range, you transport yourself. The patient still receives the care that the paramedics could provide plus additional emergency care from the emergency department staff. The only difference is that you've cut out that 10 minutes that the paramedics are going to spend on scene assessing and treating prior to transport.


*Principal number 7, "In life threatening situations, consider BLS transport if ALS arrival is longer than transport time." Protocol attached below since LACo's website sucks.

 

[ochacon80]

So as BLS providers are we basically damned if we do damned if we dont? I have been verbally raped by nurses on more than a few occasions for transporting what they consider ALS patients. I have also been yelled at by my marketing staff and owner for as they put it "takking money from the company"

Now heres another question I need clarification with. Our protocol states if transport to a hospital is less time that ALS response then we transport. But protocol also states that ALOC, SOB, and Chest pain are base contact ALS. What do we do in this situation? I have had SOB pts and I chose to transport, but again, I got reamed.