Ethics Question: BLS Turfing

[unleashedfury]

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.

I'm a firm believer that EMS systems should be a taxpayer system. Afterall in Pa we have the EMS tax which is 52 dollars a year for every working adult. If you get a citation theres a E.M.S. fund that is added to the citation. Where is all this money that the commonwealth gets going to? I don't see any improvements in our current system, we get reimbursements from insurances, memberships and donations. And that's our revenue.

In response to your reply though, your are quite correct the idea that if your transporting in a ALS rig everyone getting IV O2 Monitor was the norm for a lot of people to get the ALS1 rate, even if they don't need it. I also believe that its not our emergency to decide what interventions should be parlayed most pain can be managed with comfort and BLS skills. and those interventions should take place prior to pharmacological interventions.

 

[RocketMedic]

Blankets are not a luxury. They are BLS care, and one of the key parts of taking good care of sick people.


Fluids are often just the first step in making people feel better.

Are we here to save lives? I would say no. We are here to make people feel better on their worst days. Very rarely do we save lives. Choosing not to take good care of people because it would bother the doc (stupid protocol) or take time restocking is lazy, pure and simple.

What's the line they have to cross before they NEED pain meds in your mind?

Amen....and I just got in trouble for this attitude.

 

[triemal04]

If I had to guess I'd guess the first thing that got you into trouble was your attitude...and not your attitude towards patient care.

If I had to guess I'd guess the second thing that got you into trouble was not treating patient's appropriately.

The fact that we CAN do something does not mean that we always SHOULD do something.

 

[sir.shocksalot]

If I had to guess I'd guess the first thing that got you into trouble was your attitude...and not your attitude towards patient care.



If I had to guess I'd guess the second thing that got you into trouble was not treating patient's appropriately.



The fact that we CAN do something does not mean that we always SHOULD do something.

Sort of unfair statements to make about someone you don't know, don't you think? Not directed at anyone specifically but we all should be able to have a spirited debate and disagree about approaches to patient care while remaining respectful. IMO at least.

Moving back to the topic at hand. My personal opinion is that not every patient that presents in pain requires narcotics, not all nausea complaints need antiemetics. However, if treatment is indicated it should provided with the patient's best interest in mind. Generalized, vague complaints of mild pain might not need narcotics. That's a discussion that needs to take place with the patient. Pain treatment should be patient centered, if a paramedics decision to treat pain takes into account the patient's race or socioeconomic status they are providing biased care. If a paramedic's decision to treat pain comes down to being too tired, not wanting to ride in to the hospital, not wanting to do any paperwork, not wanting to call in for it, or considers the restock process to be too bothersome they are not putting patient care first.

Put yourself or a loved one in your patient's position. Pain is entirely subjective. The comparison to anxiety is poor. Anxiety can usually be treated adequately by talking and reassurance. I understand the argument and agree that the least invasive treatment should be used first but a lot of pain will need to be medicated. A non-narcotic option would be great but is not an option in my system.

My biggest complaint about tiered systems is that many patients go without proper treatment because they aren't "sick enough" in the subjective opinion of the ALS provider. Although an all-ALS system is not necessarily better either. For tiered systems, pain medications and antiemetics would be great if BLS providers could provide that. I think pain control largely depends on the culture of the EMS agency.

Where I am very adamant is that pain control and patient comfort are fundamental parts of patient care. What that entails is up for debate.

 

[RocketMedic]

Shocksalot, I have the same views and values. My agency apparently does not.

 

[Handsome Robb]

Judgement call, how bad is the pain? Its obviously not life threatening. Is that medic needed elsewhere? Will tying up that medic leave a significant area without rapid ALS coverage? Too many factors for a simple answer.

No there is not. If you're worried about lack of coverage or "should I treat this patients non life threatening complaint appropriately or should I turf it in case something better drops" you need to get into a new line of work.

If your system can't cover itself that's an operations problem. We exist for the patient. Otherwise we'd all be out of a job.

Who are you to say who's pain is severe or not? What do you know that the rest of us don't. How'd you like it if I scooped and ran withe your mom and a fractured hip and didn't give her any meds to keep myself available for "something better."

This attitude right here is why I'm going to school to get away from prehospital medicine at the paramedic level.

 

[ZombieEMT]

You are absolutely right, we do exist for the patient. Everyone should be treated at the highest care but life is over comfort. I would rather have the als on patients that require als for life interventions vs for a patient to provide confort care.... why is worrying about coverage an issue? As a ems system there is an obligation to your area not just one patient. In a perfect system there would be enough als and bls but perfect doesn't exist.

 

[usalsfyre]

I also believe that its not our emergency to decide what interventions should be parlayed most pain can be managed with comfort and BLS skills. and those interventions should take place prior to pharmacological interventions.

What gives you the right to determine whether it deserves pharmacological intervention or not? Your a medic student. Next time you're doing clinicals pay attention to how many people get pain meds in the ED and leave with a script. You MIGHT learn something.

 

[usalsfyre]

You are absolutely right, we do exist for the patient. Everyone should be treated at the highest care but life is over comfort. I would rather have the als on patients that require als for life interventions vs for a patient to provide confort care.... why is worrying about coverage an issue? As a ems system there is an obligation to your area not just one patient. In a perfect system there would be enough als and bls but perfect doesn't exist.

Sure it does. Every 911 system in my immediate area puts a paramedic on scene 100% of the time. I would venture to say the majority of systems in Texas (and it's a big effing state) do as well. So telling me "there's not enough to go around" is bull crap.

 

[usalsfyre]

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.

Or those systems recognized that appropriate assessment and treatment should be starting in the field rather than a taxi ride to the ED

TWhere 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.

How many patients who are suffering would choose the doubled bill for some relief? I guess we'll never know as long as some systems cling to the outdated belief of paramedics "saving lives".

 

[ZombieEMT]

So Texas is a near perfect state? Even if it is, that only counts for 1 out of 50 states in the wonderful USA. I come from a state that is far from perfect. Here there is not ALS on every call or even almost every call. Both counties that I work in, have two ALS units for the entire county. Many times calls get stacked and no ALS is not available, even when desperately needed. So not requesting ALS for comfort care, is plausible.

 

[KingCountyMedic]

guess we'll never know as long as some systems cling to the outdated belief of paramedics "saving lives".

Well where I work we do save lives. We save more lives than just about anyplace on the planet! Our system works for us. It's not just Paramedics saving lives, without our dispatch, our public defibs, our citizen CPR and our EMT's we would not be as successful as we are. BUT when someone is dying and needs that tube, needs that line, we will get it. I'd rather have a small group of medics that know how to take care of the truly sick patient than have a ton of medics that never get to intubate, or hardly ever take care of a critical patient, running around to hand out TKO lines and zofran and bill everyone at an ALS rate.

 

[STXmedic]

 

[Wheel]

Oh no

 

[DrParasite]

Here there is not ALS on every call or even almost every call. Both counties that I work in, have two ALS units for the entire county. Many times calls get stacked and no ALS is not available, even when desperately needed.

Let me guess: Hunterdon & Somerset?

BUT when someone is dying and needs that tube, needs that line, we will get it. I'd rather have a small group of medics that know how to take care of the truly sick patient than have a ton of medics that never get to intubate, or hardly ever take care of a critical patient, running around to hand out TKO lines and zofran and bill everyone at an ALS rate.

C'mon, now your introducing evidence based medicine, actual scientific data, and progressive practices.... we can't have that, we need a paramedic on every truck!!!

Our paramedics intubate on average of once a week. that's per crew, not per agency. sometimes it's even more. we are pretty good at it, because we practice it on real patients.

they also only see patient's who need ALS care (well, in theory anyway). how good of a paramedic can you be when the majorty of the time all you are doing is giving the patient a horizontal ride to the hospital? if the last time you intubated a real person was 9 months ago, what's going to happen when you look at a difficult airway?

maybe you should do your own research about what really saves lives. I can guarantee you, the science say it isn't paramedics, despite what you want to believe.

 

[Wheel]

Let me guess: Hunterdon & Somerset?C'mon, now your introducing evidence based medicine, actual scientific data, and progressive practices.... we can't have that, we need a paramedic on every truck!!!

Our paramedics intubate on average of once a week. that's per crew, not per agency. sometimes it's even more. we are pretty good at it, because we practice it on real patients.

they also only see patient's who need ALS care (well, in theory anyway). how good of a paramedic can you be when the majorty of the time all you are doing is giving the patient a horizontal ride to the hospital? if the last time you intubated a real person was 9 months ago, what's going to happen when you look at a difficult airway?

maybe you should do your own research about what really saves lives. I can guarantee you, the science say it isn't paramedics, despite what you want to believe.

In his defense he did mention dispatching, public cpr, EMT's, and public aeds as a large part of why his system works so well.

 

[DrParasite]

In his defense he did mention dispatching, public cpr, EMT's, and public aeds as a large part of why his system works so well.

actually, that statement was directed at all the people who said you need a paramedic to save lives, and a paramedic on every ambulance or else you are doing your patient's a disservice.

As screwy as NJ's EMS system is, we utlize our paramedic units in a similar manner to KingCountyMedic's system. The statement you are quoting wasn't directed at him at all.

 

[RocketMedic]

Gentlemen, I think you misunderstand the question. Systems like KCM1, SoCal FD, and NJ are excellent at specializations like arrest management and "textbook" life-threatening calls because that's what they're designed and built for. The question is not "how do paramedics do when faced with life threats", it's "is it ethical to downgrade or treat a patient to less than the necessary amount to relieve pain and suffering."

Tiered systems are cheaper than non-tiered systems and tend to have more acuity per provider...but they tend to suck at a lot of the non-life-threatening jobs.

 

[usalsfyre]

My question is why can't you provide a paramedic on every call to take care of the "BS comfort stuff" as some people like to call it a d a handful of intercept medics trained to a higher level for those "life-saving" calls. Not all medics have to be high speed low drag...

Of course that might take some humility which seems to be in short supply in many tiered systems.

 

[KingCountyMedic]

The question is "is it ethical to downgrade or treat a patient to less than the necessary amount to relieve pain and suffering.

Now that I know more of the VH1 behind the scenes story on this particular question (sorry for going off topic Rocket) I would say no, it's not ethical in your particular situation. If you are on an EMT/Paramedic transport rig and you are going to be taking the patient to the hospital regardless of who drives or who rides in back, and they are in pain, nauseated etc. etc. If your protocol or guidelines or whatever you have justify pain control you give it end of story amen.