bls transport refusing a patient

[xsullyx]

wanted to see what you guys think about this.

the other day i was working as a transport bls unit. we do get emergency calls from time to time and thus was one of them.
we get on scene to find an 84 yo male cc: hypotension pt is conscious but unoriented with grabled speech. nursing home says he has been "in and out of it all day" current vitals were bp 66/40 pulse: 50 irreg eyes: constrict sluggish
skin cool pale dry. equal adeq pms function in extemities no facial droop

nursing home took vitals 2 HOURS before our arrival and put hom in front of their desk while waiting to ems. due to his low bp, irreg heart rate, and lack of assessable orientations/pain we chose to refuse the call and pass it to als.
well this made a few nurses very upset. we made them clear the difference between als/bls and that, even tho the pt is till moving (kinda) it might be better for him to go with someobe who can monitor and shovk if necessary (no aeds on bls transport trucks in pa... yet)

the nurses then got real nice and sweet and even offered to put the pt on our stretcher and wheel him down to the truck... we called med command to confirm and gave the call to als

question i have is: our bosses ( the owners) got real pissy like when we calle in our als request. has anyone else had to contend with workplace tension because they chose to follow protocol or made a desicion based on pt needs?

ps. in pa als is inicated for ( in regards to this scene)
bp <90 sys pulse <60
pps typed on iphone srry for spell/grammar lol

 

[JPINFV]

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).

 

[Flight-LP]

Were these abnormal vital signs passed on at the time of call? How long did ALS take? What would have been your transport time to the ER?

 

[xsullyx]

those vitals were taken when i assessed the pt on scene. als to this location is awesome with no lie <3 min response time. for us to get him to the hospital lights and sirens estimated 10-15 mins. with Als so close and this guy having the lowest bp ive ever seen ( in my whopping 6 months on the job lol) i chose to standby

 

[Flight-LP]

those vitals were taken when i assessed the pt on scene. als to this location is awesome with no lie <3 min response time. for us to get him to the hospital lights and sirens estimated 10-15 mins. with Als so close and this guy having the lowest bp ive ever seen ( in my whopping 6 months on the job lol) i chose to standby

Seems reasonable.

 

[bstone]

Here is a path of less resistance- move the PT into your ambulance, call for ALS. The NH will never know.

 

[JPINFV]

I see a few issues with that.

1. Since the main location I worked accessed paramedics through the 911 system, a lot of times calling on scene is easier. To be honest, a lot of times I'm at nursing homes I know I'm at X nursing home (especially if I know how to get there on memory alone), not 123 Any Way, This Town, Na 12345. Enhanced 911 takes care of that and I can always ask the staff for the address if the dispatcher wants it confirmed.

2. 99.99% of the time, I can tell if I need to call for paramedics based on what I see at the doorway. If the patinet is breathing 40 times a minute and struggling with each breath, then I don't need to do an entire exam. As such, one provider can initiate assessment and treatment while the other goes tor request paramedics.

3. Packaging and moving the patient can normally be done while paramedics are responding. As such, the patient can normally be in the ambulance by the time paramedics arrive without increasing the EMT's patient contact time->paramedic arrival time interval since initial assessment, treatment, packaging, and egress to the ambulance is done concurrent with the paramedic response and not prior to it.

 

[medic417]

Here is a path of less resistance- move the PT into your ambulance, call for ALS. The NH will never know.

Actually if your service has the contract for transport and you call the 911 service to take the patient from your ambulance your service may have to pay. If the patient still is in care of the nurses the nursing home foots the bill.

 

[xsullyx]

wow dint know that was a possibility.

my whole basis for refusing was not wanting to accept pt care then having the guy crap out on me.

 

[CAOX3]

Your allowed to refuse a call?

 

[xsullyx]

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.

which is why it was particularyly messed up of them to "offer" to put the guy on our stretcher for us. because once hes on our stretcher we have pt care. all they cared about was gettin this dude out the door so they had one less round to do all night. no one in my family will ever go into a nursing home!

 

[MrBrown]

OK this guy sounds a wee bit crook .... you know, just a bit.

If ALS can meet you on scene significantly faster than you can either deliver the patient to hospital or meet ALS enroute then stay on scene.

Significant is not defined and requires judgement.

Now because you canot do anything for this patient except what, bit of oxygen, I don't think there's much more you could have done!

 

[DrParasite]

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.

you know, when you put it that way, it makes a lot of sense. no sarcasm, that might be a legit response.

which is why it was particularly messed up of them to "offer" to put the guy on our stretcher for us. because once hes on our stretcher we have pt care. all they cared about was gettin this dude out the door so they had one less round to do all night. no one in my family will ever go into a nursing home!

no, they didn't' want him to code on their bed, because if he does, then they need to work him. or even worse, they knew he was beyond their capabilities, and called you to transport him to a more appropriate facility.

If I was in your position, I would have put the patient on the stretcher, and started wheeling him to the ambulance. call for als on the scene, in the truck, enroute to the hospital, whatever. I don't think refusing to do the job was the right thing to do, because it wasn't benefiting the patient (assuming they were doing nothing beneficial like most nursing homes I have dealt with).

the patient needed a hospital. the patient was sick. leaving the patient in the nursing home bed was the WRONG thing, because it wasn't helping the patient. getting the patient to the hospital was the right thing to do. getting the patient to the hospital with ALS treating was even better. if the nearest ALS was on another assignment, or crashed while enroute to the nursing home, or was otherwise made unavailable, then what? now you are waiting 10 minutes for the 3 min ALS unit. then what?

load and go, call for ALS enroute.

 

[xsullyx]

drparasite you may be right. leaving the pt with th rn's who dont care may have been the wrong choice because essentially he did need a hospital. however, one cant lose sight of the fact that rn's no matter how lazy are higher trained caregivers than my lowly bls self. ( im also kinda new so the protocols are my bible for now).

but wouldnt have taking him, knowing his potential needs outweigh my training have been reckless. should i have gone all "wight knight" and taken him anyway? i tend to think not. admittedly my thought process was as much "cover my ***" as "what is best for this pt" but i guess when those two concepts came head to head i covered my ***.

im kinda new at this and really respect/apreciate more experienced providers opinion of this scenario. thank u guys

 

[triemal04]

Don't actually "leave" the patient; whether or not you transport him, stay with him until the paramedics get there. I'm sure you know that, so I'm just sayin'...B)

As for the rest of it...you did absolutely fine. If ALS is closer than the nearest hospital (and be sure to take into account how long it will take them to get to the pt's side, not just on scene, as well as how long it will take you to load the pt and move to your ambulance, not just driving time to the hospital) then this would have been the appropriate time to call them.

The only thing you might do differently is to be completely up to date on how to get an ALS ambulance in that situation, confirm how long it will take them to arrive (to be sure it was the right call), and, once you've determined that you shouldn't be transporting him, don't argue with the staff; don't waste time but get him the help he needs. Keep them in the loop about it, but, if it's your decision, then it's your decision.

 

[CAOX3]

Are nursing homes even able to treat medical emergencies? Do they have standing orders in place, or do they have to await orders from an on call MD?

For the patients benefit next time I would prepare for transportation, as was stated if there was a delay on the ALS unit arriving, you can continue on to the hospital treating what you are able to.

I am also not aware of any protocols that would require a BLS unit to wait until the arrival of an ALS unit. Most state not to delay transportation.

 

[medic417]

Are nursing homes even able to treat medical emergencies? Do they have standing orders in place, or do they have to await orders from an on call MD?

For the patients benefit next time I would prepare for transportation, as was stated if there was a delay on the ALS unit arriving, you can continue on to the hospital treating what you are able to.

I am also not aware of any protocols that would require a BLS unit to wait until the arrival of an ALS unit. Most state not to delay transportation.

Most nursing homes have much higher standing orders than you basics have. He did right saying lets stay here with you and the patient until the Paramedics arrive.

They did not delay care as it was shorter time to care getting started by waiting on the Paramedics.

The do not delay transportation is for when no higher level is available not an excuse to risk patients lives because you still believe that basics save Paramedics.

 

[CAOX3]

Easy old timer, cluttering up this kids thread with your opinions of me isnt getting them anywhere closer to the answer they are looking for.

If you want to discuss what I believe in feel free to PM me. K, thanks.

Sully you would need to consult your medical control or protocols to determine what is appropriate action in this situation.

 

[JPINFV]

Something else to consider with SNFs in terms of the "who higher" debate. On one hand, the nursing staff can do a lot more interventions both on standing orders (written orders and protocol orders) as well as physician phone orders. The one thing they absolutely can not do, though, is transport to the ER. Sometimes it's better to decrease the amount of care immediately available to achieve a higher level of care down the road.

 

[xsullyx]

oh believe me prtocols and medical command were followed and in that order. i might be newly cert'd but im not playin games out here

i think the central issues here are, follow protocol closely, follow gut and pt needs perhaps more than your own, and finally, my bosses want to make all the money they can... protocols or not.