bls transport refusing a patient

[JPINFV]

In that sense, yes. Excrement rolls downhill. Always. However, consider the fact that the best that nurses can do is yell. The boss and the marketing staff is a bit harder to deal with and brush off. However if I've got a paramedic unit across the street from my location, then there's no way I can justify not calling.

First off, can EMT-Bs in LACo make base hospital contact?

Second off, you transport even if you can't make contact. Ideally, you should have some method of alerting the hospital that you're coming in even without base hospital contact. For example, the company I worked for in OC had us give a 5 second report (age/sex/PMD/CC/ETA/anything extremely pertinent like BP for a hypotensive patient), and the dispatchers called the hospital. So the hospital shouldn't be completely unaware that you're coming in. The only possible exception (which, again, needs to be handled by a protocol adjustment to cover you) are things like MIs that may be retraiged to a cath lab even if it isn't the closest hospital. However until that exception is put in place, it's safer to transport to the closest hospital. If worse comes to worse, provide the hospital staff with a copy of your protocol and tell them to go complain to LA County Local EMS Authority (LEMSA) about that policy.

I also question about how calling for paramedics is 'taking money from the company.' The paramedics (especially if it's a non-transporting fire department) shouldn't be having you hand over care to other ambulance companies for transport. They should be transporting the patient on your ambulance. This issue got so bad for Lynch when I was there that then medical director Dr. Haynes (now medical director for San Diego County LEMSA) had to send out a letter condemning the actions of the fire department for having us transferring care to Care when paramedics were requested. In the same letter, he condemned the crew for calling paramedics because they should have been able to transport to the nearest hospital in about as much time as it took the paramedics to respond. However, fighting the fire department about issues like that on scene are counterproductive and, in my opinion, above my pay grade as an EMT-B.

 

[CAOX3]

Our protocols simply state do not delay transport, activate ALS if determined to be neccesary. Simple.

Do whats in the best interest of the patient.

 

[eveningsky339]

Now let's just hang on here... I have a few words...

Even though a nursing home RN is technically a "higher" level of care, I would never under any circumstances leave a patient with them before ALS arrived.

I worked as a CNA for a few months in a nursing home, and I encountered quite a few horror stories (and real situations) about RN/LPN responses to emergency situations.

For example, one night there was a resident who, at the start of the night shift, complained of chest pain and difficulty breathing. He was full code status. The charge nurse, however, did not know what to do. So, she waited for eight hours until the day shift nurse came in, who also did not know what to do. So, they called 911. The patient had been dead for a fairly long time when the ambulance showed up.

To be fair, there are some awesome nurses that work in nursing homes, who genuinely enjoy geriatrics. But eighty percent of the nurses I encountered as a CNA were per diem, can't-get-a-hospital-job nurses. It was awful.

I've never been on a "pure BLS" truck, but if I ever was, I would never leave a patient with a nursing home RN. h34r:

 

[jgmedic]

In that sense, yes. Excrement rolls downhill. Always. However, consider the fact that the best that nurses can do is yell. The boss and the marketing staff is a bit harder to deal with and brush off. However if I've got a paramedic unit across the street from my location, then there's no way I can justify not calling.

First off, can EMT-Bs in LACo make base hospital contact?

Second off, you transport even if you can't make contact. Ideally, you should have some method of alerting the hospital that you're coming in even without base hospital contact. For example, the company I worked for in OC had us give a 5 second report (age/sex/PMD/CC/ETA/anything extremely pertinent like BP for a hypotensive patient), and the dispatchers called the hospital. So the hospital shouldn't be completely unaware that you're coming in. The only possible exception (which, again, needs to be handled by a protocol adjustment to cover you) are things like MIs that may be retraiged to a cath lab even if it isn't the closest hospital. However until that exception is put in place, it's safer to transport to the closest hospital. If worse comes to worse, provide the hospital staff with a copy of your protocol and tell them to go complain to LA County Local EMS Authority (LEMSA) about that policy.

I also question about how calling for paramedics is 'taking money from the company.' The paramedics (especially if it's a non-transporting fire department) shouldn't be having you hand over care to other ambulance companies for transport. They should be transporting the patient on your ambulance. This issue got so bad for Lynch when I was there that then medical director Dr. Haynes (now medical director for San Diego County LEMSA) had to send out a letter condemning the actions of the fire department for having us transferring care to Care when paramedics were requested. In the same letter, he condemned the crew for calling paramedics because they should have been able to transport to the nearest hospital in about as much time as it took the paramedics to respond. However, fighting the fire department about issues like that on scene are counterproductive and, in my opinion, above my pay grade as an EMT-B.

LOL. was that your pt I took out of a Lynch rig? Lemme guess, Fullerton or Anaheim FD? I've run into nurse issues at a lot of OC hospitals, but especially the beach areas(I'm looking at you Hoag). I hate the fact that dispatchers call in report. At Care. we called in our own reports, but at CRA, they hated that I did that so much, they took all the hospital phone numbers out of the unit phones. Now, as a medic the con homes will call for a non-911 ALS call. But sometimes, we will get a call to the con home in the parking lot of our local receiving ED for a BLS unit on scene of an ALS call, the crew could literally walk the pt across the lot to the bay doors faster than I could go from my unit to the pt's room.

 

[JPINFV]

LOL. was that your pt I took out of a Lynch rig? Lemme guess, Fullerton or Anaheim FD?

2006 time frame, Anaheim Fire at the off site nursing facility on Beach for the Anaheim hospital that recently lost JACHO accreditation?

I've run into nurse issues at a lot of OC hospitals, but especially the beach areas(I'm looking at you Hoag).

You know, it's funny because Hoag was the one hospital that I've never had a problem with. It might have been because I went through the college volunteer program (CCE program) there during my undergrad so I knew a bunch of the nurses. St. Joseph's on the other hand...

 

[jgmedic]

2006 time frame, Anaheim Fire at the off site nursing facility on Beach for the Anaheim hospital that recently lost JACHO accreditation?



You know, it's funny because Hoag was the one hospital that I've never had a problem with. It might have been because I went through the college volunteer program (CCE program) there during my undergrad so I knew a bunch of the nurses. St. Joseph's on the other hand...

West Anaheim MC. Haha, I was on the Stanton unit for years and that was our primary receiving. I cannot stand AFD, except for E-4, I have gotten nothing but shabby treatment from them, if you weren't on an in-house AFD ambo, they could care less about respect and courtesy.

 

[John E]

Wow...

it's hard to believe that so many of you missed what was really happening in the OP's scenario.

Some random points.

It's a virtual guarantee that the owner of the transport company and the owner/operator of the con home have some sort of financial agreement whereby the ambu. company gets called for their transports in exchange for a kickback from the ambu. company.

The con home gets investigated when they call for ALS transport too many times, that leads to the owners/operators getting fined or losing patients, ie, money.

The ambu company thinks that the OP was costing the company money because they can't defraud Medicare or bill the patient's insurance company if the patient ends up being transported by either the ALS company or by public/FD ambulance.

The "nurses" at the Con home are either aware of the financial arrangements that have been made between the owners and the ambu company or they themselves have also been convinced financially thru bribery to call that particular company for transporting patients.

None of what transpired has anything to do with the educational standards of EMS or the legal standing of an RN vs an EMT in regards to authority over patient care. It has to do with money.

John E

P.S. to the original poster, you did exactly what you should have done from a patient care POV, unfortunately the patient care POV is ALWAYS secondary to the financial interests at play in the private/transport ambulance company world.

 

[JPINFV]

Oh, I don't think anyone ever missed that point. However, points such as,

well we're a transport company primarily, so whenn doing transports u can assess and then say " hey this is a bit outta my league". but since we are a bls squad with no als affiliation... its refusing to take the call and giving it to some als company. the only reason this can be done is because the pt is already under the care of a higher ranked care provider ( rn's ) and we hadnt yet assumed pt care.

(emphasis added)

deserves discussion.

 

[jeeprnovru]

i would have just wanted to transport with possible als intercept in route....you guys can do that over there i hope....h34r:

 

[spike91]

I volunteer in New York, and when we get a patient that we feel is in need of ALS, we request the ALS and continue with transport unless an ALS provider is in the immediate vicinity. Otherwise we'll do an intercept with the provider, he'll jump on our rig and get to work en route.

Keep in mind, however, all of our rigs are ALS equipped, so I can imagine many wouldn't be capable of this kind of set up.

 

[firecoins]

A nursing home is not really a higher level of care. It might be technically but the RNs in a nursing home can not do anything w/o MD approval. When we accept care, the RNs are not a qualified 911 receving facility. BLS units are free to all for medics reguadless of the desires of the SNF.

 

[JPINFV]

A nursing home is not really a higher level of care. It might be technically but the RNs in a nursing home can not do anything w/o MD approval. When we accept care, the RNs are not a qualified 911 receving facility. BLS units are free to all for medics reguadless of the desires of the SNF.

Technicalities have a tendency to hang people.

EMS providers can't do anything either without physician approvial (who do you think signs your protocols/standing orders? Do you think EMS is the only place with standing orders?)? Additionally, what PRN orders are currently written for that patient?

I'm not, and will almost never say, not transport or accept a patient with an emergency from someplace in the community for transport to an emergency department. However there's better arguments than the "EMS has psuedo-independent practice rights" argument that gets thrown around every time someone feels the need to compare EMS providers to nurses. How about this argument? The ends (emergency department) justify the means (EMS transport, even if by EMTs).

 

[firecoins]

Technicalities have a tendency to hang people.

EMS providers can't do anything either without physician approvial (who do you think signs your protocols/standing orders? Do you think EMS is the only place with standing orders?)? Additionally, what PRN orders are currently written for that patient?

The nurses at nursing homes seem to not put people on non rebreathers. Whatever standing orders they have seem to not be sufficient. Accept the pt and call for ALS. A SNF seems to insufficient for emergencies.

 

[Akulahawk]

Technicalities have a tendency to hang people.

The nurses at nursing homes seem to not put people on non rebreathers. Whatever standing orders they have seem to not be sufficient. Accept the pt and call for ALS. A SNF seems to insufficient for emergencies.

I have transported patients from SNF's that couldn't put any patient on any higher O2 flow rate >3 LPM without MD orders. One sticks out in my mind. They called for "weakness & lethargy", said they had the patient "all the way up on 3 liters". Weakness & lethargy? Yeah... I can see that... when the patient is clearly in respiratory distress (probably PNA) and not oxygenating well... :censored:

That patient went out fast... on 15 LPM... SNF RN was pissed. Did I care? Nope. That facility wasn't able to provide proper care so the call became a "scene call" instead of what would have been considered an IFT, and I treated it as such. Besides, she transferred care to me, and I must follow MY protocols instead of the SNF's. SpO2 at arrival at the closest ED was something like 83% on that much O2. I transported because it was quicker for me to deliver her to the ED than get ALS ambulance to her.

Oh, and this "Weakness & Lethargy" thing was a favorite complaint given to BLS ambulance companies to get them to respond instead of 911. I've seen that used instead of "chest pain", "Stroke", "Septic shock"... The list goes on... I'd transport if the ED was closer time-wise than the nearest ALS ambulance or engine (I worked BLS at the time) and turn over to ALS if the reverse was true.

 

[JPINFV]

I'd transport if the ED was closer time-wise than the nearest ALS ambulance or engine (I worked BLS at the time) and turn over to ALS if the reverse was true.

I'm not [saying], and will almost never say, not transport or accept a patient with an emergency from someplace in the community for transport to an emergency department.

/shrugs...
//forgot a word, but is implied by what was placed in the comma section...
//Wonders if people read entire posts anymore...

 

[Akulahawk]

/shrugs...
//forgot a word, but is implied by what was placed in the comma section...
//Wonders if people read entire posts anymore...

JP: I understood what you meant.

 

[MonkeySquasher]

Sully -

DrParasite hit the nail on the head. You are, at all times, a patient advocate. Always do the right thing for your patient, and what your patient needs.

You aren't so "lowly" of an EMT at the Basic level... His BP was in the tank, yes. I'm assuming the NH can't do IVs, so you're on your own. Oxygen, Trendelenburg position, cover with a blanket, package into your ambulance for transport... All things you can do to benefit your patient, and not feel helpless. Sure, they aren't the "silver bullet" for his condition, but it's better than a phone call and waiting period. Then ALS gets there, he's already in the ambulance. They do an IV, and do the monitor and any further treatment during transport.

Now I know saying this may anger some who read this, but... You, as a Basic EMT, are a BETTER level of care when you show up. Many NH/SNF can do more than you can, but as stated, they can't transport. And to do interventions, they have to call an MD for Orders to do pretty much anything not already in writing, as PRN meds are rarely emergency-oriented. You, meanwhile, operate under standing orders for treatments based on patient presentation, and can then just package up and rush to a hospital if things go south.

Sully, I don't know about PA, but in my state, on an ambulance, a typical RN is the same level of care as a Boy Scout, unless doing an IFT under orders of an MD, or a CCN, or something. As Linuss stated, "They called you because they are no longer able to cope with the patients condition." When you get there, you make patient contact, you are now incharge. And since that patient is unstable, your clock is ticking. Waiting 5 minutes for ALS won't burn you, no. But that doesn't mean you don't initiate treatments and begin packaging, you know?

However, watch closely EVER refusing to take someone while at work. Saying "I won't take this person for X Y Z reasons" is a good way to get fried some day, unless (like you said) you somehow have a doctor backing you up. And document the hell out of it, with names and time and signatures, if possible.

If you had started transport and the guy's condition worsened, it's the same as any other patient. Follow your proper protocols and work it into the hospital. Being BLS, there's only a handful of things you can do, so you should have no excuse not doing all of them.

There's a quote from the movie SWAT which I stand by... "Sometimes 'doing the right thing' isn't doing the right thing." Remember - You can never be faulted for doing what you truly believe to be in your patient's best interests.

 

[Rsion4191]

At most NHs , nurses need an MDs approval (as previously stated) . But even here in SoCal , MDs AREN'T EVEN AT THE NHs . They've gotta wait for phone orders or wait for written orders to be brought in . I understand how you feel about being new . I've only been in the field for six months as well .