Ethics Question: BLS Turfing

[NomadicMedic]

A woman with a ruptured ovarian cyst that's been in pain for days ...

A guy with kidney stones...

A kid with sickle cell...

My mom with a fractured hip.

Which one gets pain management?

...or do you decide not to bother the doc for any of them?

 

[triemal04]

Well obviously, there is some judgment involved there.....

It's not that obvious from reading many of the responses in the dozens (at least it seems like that many) of different threads this has come up in; the continual mantra is "if the patient says they are in pain you have to treat them, and if narcotics are all you have that is perfectly appropriate."

I still can't understand why people here will harp about how people in EMS need to be better educated (we do) and need to be better at assessing patients and making appropriate, non-protocol driven decisions (we do) and then say something as asinine as that.

 

[Rialaigh]

A woman with a ruptured ovarian cyst that's been in pain for days ...

A guy with kidney stones...

A kid with sickle cell...

My mom with a fractured hip.

Which one gets pain management?

Which ones are identifiable acute events? Your clearly trying to trap me into saying the fractured hip and then tell me why I am wrong for not medicating the other 3....

If the sickle cell patient has been in pain for days its not acute
The ovarian cyst you said days of pain, again not acute.
The kidney stone may have been in pain for days..not acute.

I do not in any way feel responsible for treating non acute non identifiable pain. Could and would I choose to treat this occasionally. Yes, but don't tell me it's my responsibility legally and ethically as an EMS provider to treat pain in non acute conditions with non descript pain from people that quite frankly know they could have had someone pick them up and take them to the hospital yesterday. Now very symptomatic pain that is causing some detrimental symptoms absolutely treatable.

 

[triemal04]

A woman with a ruptured ovarian cyst that's been in pain for days ...

A guy with kidney stones...

A kid with sickle cell...

My mom with a fractured hip.

Which one gets pain management?

...or do you decide not to bother the doc for any of them?

Show me the patient. I've treated people with each of those problems and not all of them required medications to relieve their pain, either from me, or in the hospital. Of the ones that did, not all needed more than tylenol or toradol.

And I've had patients who had the above who required narcotics, sometimes in very large doses.

But then...I always like to assess my patients and decide on an appropriate treatement before starting to treat them.

 

[NomadicMedic]

Because you ARE wrong for not medicating the other three.

I don't know how to make it any clearer. Wait til you have a kidney stone. Wait til you get in a car wreck and fracture your leg. Wait til you are in pain and the paramedic has a bag full if pain meds and decides NOT to give them to you because he doesn't want to bother the doc.

It's not YOUR pain. It's the patients. YOU are not allowed to judge who's worthy and who's not.

 

[Rialaigh]

Because you ARE wrong for not medicating the other three.

I don't know how to make it any clearer. Wait til you have a kidney stone. Wait til you get in a car wreck and fracture your leg. Wait til you are in pain and the paramedic has a bag full if pain meds and decides NOT to give them to you because he doesn't want to bother the doc.

It's not YOUR pain. It's the patients. YOU are not allowed to judge who's worthy and who's not.

Then you can't judge who's anxious or not, I demand you give benzos to every patient that complains of anxiety next shift....<_<

Next patient that says their thirsty absolutely has to get a liter of fluid as well...

 

[NomadicMedic]

Then you can't judge who's anxious or not, I demand you give benzos to every patient that complains of anxiety next shift....<_<

I never made the statement that I withhold medication because I don't want to bother the doc. That was you pal.

 

[Rialaigh]

I never made the statement that I withhold medication because I don't want to bother the doc. That was you pal.

It's not YOUR pain. It's the patients. YOU are not allowed to judge who's worthy and who's not.

That wasn't the point you made in the last several posts, you made the point that who am I to judge pain, and who are you to judge anxiety or dehydration....

 

[CentralCalEMT]

That is one thing I like about my system. If a paramedic is on scene (which is most of the time as we are a rural system so most of the few ambulances we have are ALS) then the paramedic rides in the back with the patient.

Personally, as a medic, I like this rule because in 2014 we are not just there for life and death emergencies. Being a medic is about more than pushing medications. Sometimes we are the only people who take the time to explain to our patient's how to take care of themselves. There are so many people lacking primary care, or having primary care MDs that are too busy to explain things. For example, the other day, I had a patient with a history of CHF on diuretics. She said she had not been taking them. When I asked why, she said she did not think it was important. I explained what CHF was and why taking medications as prescribed was so important. It was like a light went on in her head and she promised to take better care of herself so she could be there for her grandchildren. Did I do anything remotely ALS on that call besides Monitor/IV? Absolutely not. Was I able to use my knowledge to help someone better themselves? Yes I was. Not that some EMTs can't do the same' but a lot do not have the knowledge base of that disease process and pharmacology to have that discussion with the patient.

I came from the LA county system where fire responds in either an ALS engine or ALS squad and the ambulance is BLS. The fire medic has the choice to turf the patient to BLS and go back to the station. I can't even begin to describe the number of chest pain calls that became "chest wall discomfort" shortness of breath that became "cough and congestion" and altered that became "general weakness" so the paramedic could justify shipping the call BLS. To me that is both unethical and downright wrong.

Now I understand every system is different and what works for me might not work for someone else in a different system. However, I like the way we do things in my system because I believe it puts the patient first.

 

[Wheel]

A woman with a ruptured ovarian cyst that's been in pain for days ...

A guy with kidney stones...

A kid with sickle cell...

My mom with a fractured hip.

Which one gets pain management?

...or do you decide not to bother the doc for any of them?

I would say all of them, if the presentation warrants it. Any of them that are in distress will certainly get it. I tend to err on the side of treating the pain, especially in patients with a high pain tolerance (like sickle cell), but physical exam and history will play a part in the decision to medicate a patient, just as with all medications. A blanket statement can't be made about treating pain.

 

[NomadicMedic]

That wasn't the point you made in the last several posts, you made the point that who am I to judge pain, and who are you to judge anxiety or dehydration....

I don't know if you're being deliberately obtuse because you enjoy an argument... Or you really believe what you're writing. I'm hoping you're not really this guy...

I don't look at my protocol book and ask for narcotics for every patient that complains of pain 6/10 or higher (as the protocol book says I CAN do).

...medication of patients in pain is not a NEED...it is a luxury...

Because if you are, you're a disgrace.

And with that, I'm done with you.

 

[Rialaigh]

My point about anxiety stands. Anxiety consistently makes almost all serious and non serious conditions worse rapidly. It causes elevated blood pressure, tachycardia, rapid breathing. It can cause people who have an complaint entirely different from anxiety to pass out, become hypoxic or hypercapnic. It exacerbates a variety of conditions that can acutely deteriorate in a short period of time. Yes no one seems to be outraged when we "withold" benzo's from patients complaining of anxiety.

Why is it that pain management, which by the way pain has many many less of the negative possible side effects than anxiety, is the life or death issue.

 

[triemal04]

Because to decide if someone needs pain management is to judge them! And judging someone is baaaaaad! When you judge someone an angel loses it's wings! And a baby cries! And a puppy dies! And...

Sorry...had to go vomit for a minute.

This ignores the fact that the above is a load of BS, and ignores, yet again, that our job is to assess and examine patient's and treat them in a medically appropriate manner, to the best of our abilities, within the limits imposed by our equipment and surroundings.

To not do that, as would be done by those who advocate treating every complaint of pain without further thought is wrong, and a disgrace.

End of story.

 

[mycrofft]

Naw, just to protocols.
I keep saying "go to the protocols" because some folks here seem to be bent on finding ways to end-run protocols. Most of the "old heads" seem not to.

I've seen people with serious injuries and no shift in vitals because either they didn't know theory were hurt that bad, they were drunk or high, they were culturally stoic, or they were chronically in pain so it didn't faze them. I got brought to the mat a few times trying to make vitals a definitive sign of pain; they admitted that ACUTE affect (agonal) will tend to match vitals (higher BP/Pulse and sweat) more than longer term issues.

We keep going here to the "life or death issue". EMT's and paramedics have traditionally been trained about life or death issues because their origins are with MVA's and maybe multi casualty events and no further resources. Real medicine, not bandaid and splint techs, includes more than slapping the most on the worst and going the fastest. Cut the drama, most field EMS is not going to be life or death. I hope!!

 

[unleashedfury]

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.

While this is the way a P/B is supposed to work it rarely works that way, In areas around here where a ALS squad is the primary provider they are dispatched for everything from stubbed toes to cardiac emergencies the ALS provider is supposed to assess the patient and appropriately triage to BLS or continue with ALS assessment and interventions. Is it right that we can legally charge an ALS1 rate for a patient who requires no ALS interventions no do we yep

I medicate patients that NEED the pain medication to be treated, moved, transported, extreme pain that is affecting vitals or breathing..etc... Other medication of patients in pain is not a NEED...it is a luxury just like a blanket to keep them warm or fluids to rehydrate them a bit before the ER.

Blankets are not a luxury, its primary care, If we showed up to your house to lets say take your mom to the hospital for weakness and flu like symptoms and throw her on the stretcher strap her in and take her to the hospital no pillow, no blanket just a sheet on the litter, because blankets are a luxury.. would you feel that we provided excellent service?? Probably not. Our job is to assist patients in treating their symptoms, and providing care, sometimes just comfort measures like blankets or positioning is providing care.

That is one thing I like about my system. If a paramedic is on scene (which is most of the time as we are a rural system so most of the few ambulances we have are ALS) then the paramedic rides in the back with the patient.

Personally, as a medic, I like this rule because in 2014 we are not just there for life and death emergencies. Being a medic is about more than pushing medications. Sometimes we are the only people who take the time to explain to our patient's how to take care of themselves. There are so many people lacking primary care, or having primary care MDs that are too busy to explain things. For example, the other day, I had a patient with a history of CHF on diuretics. She said she had not been taking them. When I asked why, she said she did not think it was important. I explained what CHF was and why taking medications as prescribed was so important. It was like a light went on in her head and she promised to take better care of herself so she could be there for her grandchildren. Did I do anything remotely ALS on that call besides Monitor/IV? Absolutely not. Was I able to use my knowledge to help someone better themselves? Yes I was. Not that some EMTs can't do the same' but a lot do not have the knowledge base of that disease process and pharmacology to have that discussion with the patient.

I came from the LA county system where fire responds in either an ALS engine or ALS squad and the ambulance is BLS. The fire medic has the choice to turf the patient to BLS and go back to the station. I can't even begin to describe the number of chest pain calls that became "chest wall discomfort" shortness of breath that became "cough and congestion" and altered that became "general weakness" so the paramedic could justify shipping the call BLS. To me that is both unethical and downright wrong.

Now I understand every system is different and what works for me might not work for someone else in a different system. However, I like the way we do things in my system because I believe it puts the patient first.

IMHO if a primary care physician "doesn't care to explain what they are treating their patients for, or tells the patient they don't have time to explain things" Its time to find a new physician. I am sorry its my body, I have the god given right to know whats going on with me, what the medications you are prescribing are going to do for me, and if I don't have a clear understanding as a non medical person, as my Primary care physician you should be more open and helpful,

To initially respond to the OP's post. most of what you are stating is a judgment call, to withhold interventions from any patient is unethical. But in the same way it comes down to HPI and a solid assessment. why is the patient sick with N/V. are they a cancer patient receiving chemotherapy? are they sick with a viral infection? etc. If N/V is motion sickness related anti-emetics like Zofran are ineffective. Also take in consideration sometimes the closest ALS is a ED. I.E. we provide primary coverage for a town that the hospital is in and 3 minutes away so to have a ALS truck dispatched and enroute to the scene I can have the patient at a higher level of care faster.

As far as the pain management portion of this thread. This is subjective to the patient. not everyone needs to be pumped full of narcotics to subside their pain. we simply forget that pain management is all or nothing with drugs, there is other interventions first. Often patients can have their pain subside with positioning comfort, and even things like heat or Ice. I've had patients with hip and extremity fractures that had pain relieved by proper positioning for comfort. or simple interventions like ice. and to continue no need to dump the drug box for pain management you can titrate up to the max for pain management depending on your transport time. If a patient pain subsides with 2mg of morphine or 50mcg of fentanyl why should I use the max dosages available to me?

 

[ZombieEMT]

Working in New Jersey, this is a debate that we have frequently at a BLS level. Generally, I do not request an ALS intercept just because of severe pain and/or nausea. I always evaluate the benefit vs loss. If the patient can go with the pain and/or nausea then I will not tie up an ALS unit. If the pain or nausea lead to other life threatening issues or other life treatening issues occur, they will be requested. I might also request ALS for pain, if the pain has become so severe that we can not even move the patient to transport with a yelping scream.

 

[ZombieEMT]

So what's the line they need to cross to qualify for non-luxury pain meds in your mind?

I think the line is where the need for pain medications turns from comfort care to care for immediate life threats.

Please do not take this response in the wrong way. I am speaking soley from the system that is ran in New Jersey. While comforting my patient is a priority, I will not request ALS for comfort care. However, if ALS is with us or needed for a seperate issue, treat the pain too.

I see it like this, bandaids are not a requirement for stock on an ambulance in New Jersey. I guess the idea is that people do not call an ambulance for something that just needs a bandaid. However, that does not mean if I go out for a patient who has other injuries or medical complaints requiring an ambulance, that I would not put a bandaid on to treat the minor abrasion/laceration.

 

[jgmedic]

So does any patient that is given a medication then require ALS care during transport, I believe, if your system has competent EMT's they can adequately manage a patient with peripheral access and moderate amounts of pain meds or anti-emetics. My system requires all patients transported by 911 to have a paramedic attendant, which I am more than ok with. I give pain meds and Zofran more than most medics, but barring any other circumstances, I think your typical N/V patient with Zofran given or a patient with non-traumatic pain given MS could be transported BLS if the system allowed, I mean, how many BLS IFT patients are medicated prior to transport anyway?

 

[abckidsmom]

I think the line is where the need for pain medications turns from comfort care to care for immediate life threats.

Please do not take this response in the wrong way. I am speaking soley from the system that is ran in New Jersey. While comforting my patient is a priority, I will not request ALS for comfort care. However, if ALS is with us or needed for a seperate issue, treat the pain too.

I see it like this, bandaids are not a requirement for stock on an ambulance in New Jersey. I guess the idea is that people do not call an ambulance for something that just needs a bandaid. However, that does not mean if I go out for a patient who has other injuries or medical complaints requiring an ambulance, that I would not put a bandaid on to treat the minor abrasion/laceration.

I guess as a BLS provider you have to bring in to play the risk/benefit analysis of calling ALS, waiting for them to arrive, turning the patient over to them, etc, vs how quickly you can arrive at the hospital by just driving the patient in.

In my rural system, if I choose not to "comfort" the patient with pain meds or anti-emetics, that sentences the patient (and the providers, BTW) to a looooong ride to the hospital.

I really, really like to get the patient loaded, start on the way to the hospital, give fentanyl and Zofran, tuck the patient in, and have them rest on the way to the hospital. I HATE listening to someone puke, almost as much as I hate puking myself. I way prefer getting them comfortable and letting the ride be quiet and uneventful.

 

[KingCountyMedic]

The majority of patients that require ambulance transport are BLS patients. I worked a long, long time in a system that had a paramedic on every rig and you were encouraged to put lines in every one you could. "O2, IV, Monitor every patient you can." This was commonly pushed at staff meetings. Ambulance billing is one of the biggest scams going in my opinion. Where I work now we only transport true ALS patients that need real ALS care and we don't bill for it, it is all tax payer supported. How many patients that get pain and nausea meds that can probably do just fine without them are told before hand that it will likely double their bill and they could possibly get sent to collections for not paying? So in answer to the original questions I would say mostly yes although there's always exceptions.