HELP! My EMT-I thinks she's a paramedic!

[paragod]

Okay, so this is my first posting to this board. I am so glad that there is a community online for all of us crazy EMS people to chat.

My wife and I are paramedics at this service. We are both seasoned medics, did 911 at a very busy service for a few years, and decided to move to the beach. We got on at a quasi-critical care service, and are, by far, the most experienced and competent people here.

At one point, I was assigned a new hire partner who was in EMS years ago, the did police work, worked in an MD's office, got her LPN, and decided to get back into EMS as an EMT. Well, we do a lot of trael out of town, and the first weekend, we didn't get any critical patients, so I told her to ride the calls, and I would get us where we were going. Well, that worked out fine for that weekend, but as time went on, she started talking about how she had been in a terrible police car accident and was afraid to drive. So, I drove most of the time, and we never were up for a call when a critical patient came through, so I just went with it.

Well, one day, predictably, we got a serious patient. It was a time sensitive thing. I got in the back of the truck and started evaluating the patient. She told me to get enroute, she would take care of everything on the road. Well, we didn't have time to argue, though I did tell her that I wanted to evaluate the patient first. We took off, and I asked my wife to take her as a partner. She did, and she has not had any issues like this from her.

Well, one day, my wife and I went home during the shift, as we are all allowed to do, and a Call came in. It was an ALS call at a nursing home, and this EMT decided to take off with an EMT-Basic and run this call. My wife and I started to head in that direction, and the EMT called and said "it's okay. It's not a bad call." Well, we decided to meet them at the ER, and lo and behold, here they come around the corner lights and sirens. When we all got back to the station, I let her have it, telling her I would not sign off on this activities anymore, and if she screwed it up, it was on her.

Well, now we have another new hire, who is a fresh paramedic, and completely incompetent. The director wants to retrain him, hoping to give him a chance to get better, and he is understrict orders to only ride with me or my wife. But now, the EMT wants to take him, and is pushing really hard for it. She went as far as telling me "if it's a code, I can run the code with him. I can handle that."

The thing that complicates the situation is that she and my wife are very, very good friends. Going to the director would sort of be like a betrayal. Frankly, when the first incident happened, I really didn't want to be her friend anymore. This is just one of many slights that she has done to me. My wife swears she has no problem with her, but I have to still work with this EMT on alternating sundays, nevermind the fact that she is constantly trying to jump my calls. When she is with me, she acts like she has forgotten she is not a senior medic!

Help!

 

[vquintessence]

First off, I'm amazed the name "paragod" wasn't already taken! Also, welcome.

Well, one day, predictably, we got a serious patient. It was a time sensitive thing. I got in the back of the truck and started evaluating the patient. She told me to get enroute, she would take care of everything on the road. Well, we didn't have time to argue, though I did tell her that I wanted to evaluate the patient first. We took off, and I asked my wife to take her as a partner.

With that first instance of a time-sensitive pt, how is it that the intermediate was responsible for the call and not you, the paramedic? Is it a GA thing?

... a Call came in. It was an ALS call at a nursing home, and this EMT decided to take off with an EMT-Basic and run this call. My wife and I started to head in that direction, and the EMT called and said "it's okay. It's not a bad call." Well, we decided to meet them at the ER, and lo and behold, here they come around the corner lights and sirens. When we all got back to the station, I let her have it, telling her I would not sign off on this activities anymore, and if she screwed it up, it was on her.

I'm confused, what liability do you have when you're cancelled en route? I think the danger lies when you continue on despite being cancelled by BLS.

Well, now we have another new hire, who is a fresh paramedic, and completely incompetent. The director wants to retrain him, hoping to give him a chance to get better, and he is understrict orders to only ride with me or my wife. But now, the EMT wants to take him, and is pushing really hard for it.

If your med director is already eyeing him, at least your company is aware of the new hires situation. If the "trouble EMT" even has any clinical issues would they still be so stupid just to cater to her demands? What about just level of care provider as well as experience?

I don't know man, sounds like there is bound to be more animosity between that woman, your wife and yourself. Face it now before anything bad happens that could hurt the public, yourselves or give your agency a black eye. Set up a meeting with your medical director, express your concerns between the EMT-I and the new paramedic. See where that gets the ball rolling.

 

[paragod]

actually, i am also amazed it wasn't taken. Thought I'd give it a shot!

Anyway, to answer your question, I was trying to take responsibility for the call. We had a 45 min. transport, that's why it was time sensitive. At the time, my policy was to not engage in confrontation in front of patients. After that call, she was no longer my regular partner.


As for the other question, we aren't supposed to operate BLS units. She took off on her own with my partner, who was a basic. We are non-emergency, and occasionally get a call from a nursing home that should have been routed through 911. This was one of those calls. Every facility that calls us knows that we are non-emergency, rather more on the critical care end, and, this facility was told it would be 30 minutes before someone could get there. The elected to wait rather than call 911. This EMT-I heard the call, and tore off with the Basic. The dispatcher told us that they were jumping the call AFTER we were already en route POV.

Maybe that clears things up some?

 

[VentMedic]

We got on at a quasi-critical care service,

What type of service is this?

When she is with me, she acts like she has forgotten she is not a senior medic!

Apparently you have already allowed this to happen where she has the patient care and you are driving.

Are these calls contracted as ALS? Are they billed as ALS? SCT? Are you signing the report sheets as being the provider in charge of the patient...while driving....under an ALS billing code?

Well, now we have another new hire, who is a fresh paramedic, and completely incompetent. The director wants to retrain him, hoping to give him a chance to get better, and he is understrict orders to only ride with me or my wife. But now, the EMT wants to take him, and is pushing really hard for it.

If this is allowed and the company is allowing all of this to happen, I would say it is time to fine a different company. As well, you should remember what your own responsibilites are to the patient and the facilities that contract you for specific services even if you call them "quasi-critical care".

This was one of those calls. Every facility that calls us knows that we are non-emergency, rather more on the critical care end,

Can you define "critical care" as it pertains to your service?

 

[marineman]

The way it works at my company the senior medic is in charge of the ambulance but not the boss, we are a team. With that we expect the senior medic to take control and make a decision and we will follow, granted it's a 2 medic system so we don't really have the same problem but I think it's your job to stand up and say I'll take patient care. A senior medic needs to have that ability to make a decision and take charge. Explain to the partner it's nothing personal but you are the senior medic and she's an EMT-I and it's your job to care for patients requiring advanced care. If she can't separate her work conflicts from personal friendships that's her problem not yours, at work your duty is to your patients not your friends.

 

[paragod]

Our primary purpose at this service is to transport critical patients to higher facilities. However, calls of this type are infrequent, so there are contracts with various skilled nursing facilities that keep call volume, and therefore revenue, up. I didn't create the company, I just work here. I have real problems with the way some things go around here, but there is not a lot I can do about it right now. If I rise up against it without a back-up, I will be fired and blacklisted. My wife and kids can't afford that.

This was the first time a serious call had come up with me and this particular partner. The rotation just didn't fall in a way to make it happen sooner. I allowed her to ride BLS calls, and, apparently she took that to mean she rides all calls.

 

[VentMedic]

I allowed her to ride BLS calls, and, apparently she took that to mean she rides all calls.

As for the other question, we aren't supposed to operate BLS units.

Is the patient billed for an ALS or BLS truck and services?

 

[paragod]

and let me just add that I know i dropped the ball on this. I know I got played. i know i was gullible and didn't assert some sort of rotating call thing early on. if i had, this could have been avoided. i have tried to be nice, but you can't make everyone happy, and i just need to do what is right by my patients. got it.

has anyone had this happen before. has anyone had an overbearing emt-i or emt-b take over a truck? what did you do?

 

[paragod]

Is the patient billed for an ALS or BLS truck and services?

i think we are getting lost in semantics here. when i say BLS truck, i mean that our station, not company, but station policy is to run only ALS units, meaning at least one paramedic on the unit. As far as I know, and when I fill out the billing ticket, anything falling below ALS gets billed as BLS. In georgia, just because a paramedic is in the back does not make the call necessarily an ALS call. A BLS only truck is one manned by only EMT-I's and is has only EMT-I drugs, which are very limited in this state

 

[daedalus]

Paragod, you are in charge of your unit while you are the paramedic on board. I understand you have a difficult situation with respect to the fact your wife is a friend of the partner you are having problems with, however you must place your patients first. As you know, many of these critical transfers have infusions of medications that the EMT B/I will have never heard of, like Integrilin. Thus, they have no idea what to looks for if the patient is getting too much or too little of these drugs.

 

[VentMedic]

Well, one day, predictably, we got a serious patient. It was a time sensitive thing. I got in the back of the truck and started evaluating the patient. She told me to get enroute, she would take care of everything on the road. Well, we didn't have time to argue, though I did tell her that I wanted to evaluate the patient first. We took off, and I asked my wife to take her as a partner. She did, and she has not had any issues like this from her.

In this situation you described earlier with a sick patient in the back but you were driving, did you officially downgrade that patient on paper so your EMT(I?) partner could stay with that patient?

i think we are getting lost in semantics here. when i say BLS truck, i mean that our station, not company, but station policy is to run only ALS units, meaning at least one paramedic on the unit. As far as I know, and when I fill out the billing ticket, anything falling below ALS gets billed as BLS. In georgia, just because a paramedic is in the back does not make the call necessarily an ALS call. A BLS only truck is one manned by only EMT-I's and is has only EMT-I drugs, which are very limited in this state

Just having a Paramedic on a truck does not make a truck ALS. It must be licensed for that level. Many Paramedics work BLS trucks and perform at a BLS level.

How I hate this "BLS" and "ALS" crap!

 

[paragod]

Paragod, you are in charge of your unit while you are the paramedic on board. I understand you have a difficult situation with respect to the fact your wife is a friend of the partner you are having problems with, however you must place your patients first. As you know, many of these critical transfers have infusions of medications that the EMT B/I will have never heard of, like Integrilin. Thus, they have no idea what to looks for if the patient is getting too much or too little of these drugs.

you're right, but that falls under ALS, which she has not ridden. i guess i have been unclear because we have been getting hung up on ALS vs. BLS. Let's just say, I wanted to ride the call. the patient in question was not particularly critical, not even als, but i wanted to ride. the problem i am having here isn't als vs. bls. i got that part down. the problem is the personal side of it. the problem is a person of lower training taking the opinion of herself that she is of higher training. again, my wife now rides with her, and does not have this problem. she thinks its a man thing, in which case there's nothing that can be done

 

[paragod]

Paragod, you are in charge of your unit while you are the paramedic on board. I understand you have a difficult situation with respect to the fact your wife is a friend of the partner you are having problems with, however you must place your patients first. As you know, many of these critical transfers have infusions of medications that the EMT B/I will have never heard of, like Integrilin. Thus, they have no idea what to looks for if the patient is getting too much or too little of these drugs.

In this situation you described earlier with a sick patient in the back but you were driving, did you officially downgrade that patient on paper so your EMT(I?) partner could stay with that patient?



Just having a Paramedic on a truck does not make a truck ALS. It must be licensed for that level. Many Paramedics work BLS trucks and perform at a BLS level.

How I hate this "BLS" and "ALS" crap!

yeah, for the purposes of this station all of our trucks are physically ALS units. and this call really didn't fall under the definition of cardiac monitor, intubation, vents, etc. it was one of thos calls where your gut tells you it may go south. that's why i wanted to ride. the intent and purpose of the call was BLS and, unless the billing office fudged it, it was billed as such.

 

[Ridryder911]

I too agree, that I will be glad when EMS matures enough to disband the BLS/ALS verbiage.
I disagree that it is the unit that is either ALS or BLS. It all depends upon the State issuing the license/certification. For example we have individual protocols for BLS services. In other words a Paramedic maybe working for a BLS service but only they are allowed to administer ALS procedures/care. Therefore; it is the individual not the service rating at the time. Don't agree but doubt it will change as more and more services are downgrading their level license and still can bill at a ALS when they have the personnel.

I agree also, your the Paramedic. Any patient that requires ALS care should be cared by you the highest level of care. One maybe in serious trouble just allowing another to supersede their level. It's your license, their should be no choice for your wife to even think about it.

R/r 911

 

[paragod]

just an aside, i think this is another problem with EMS. no uniformity in the language or standards.

 

[paragod]

I agree also, your the Paramedic. Any patient that requires ALS care should be cared by you the highest level of care. One maybe in serious trouble just allowing another to supersede their level. It's your license, their should be no choice for your wife to even think about it.

R/r 911

well you are right, but like i said, that's not what i'm trying to get across here. i will not ever allow an EMT-I to perform ALS duties or procedures.

and the hard part about it is i feel bad even bringing this up. fortunately it hasn't gotten to a patient threatening level. right now, it's just about stepping on my toes with this attitude that she has like she is just going to take it all over without any regard to my training or my experience. she's a great person, but for whatever reason, just doesn't repect the hierarchy that i think, and everyone else seems to think is in place.

 

[VentMedic]

Let me clarify my statements about ALS or BLS billing. If my facility calls your company and requests an ALS truck or CCT with an ALS provider to watch our patient because that is the level of care the physician has determined the patient to be, that is the level of care we expect to get. To switch to a lower level provider, while the facility or the patient is being billed for ALS, is fraud...plain and simple. We don't expect the Paramedic to just be in the truck. We expect that Paramedic to be attending to the patient. This is one very easy way to lose an IFT contract and get a Medicare investigation as well as a visit from the State office. Is this why you refer to your service as "quasi-Critical Care"?

 

[paragod]

Let me clarify my statements about ALS or BLS billing. If my facility calls your company and requests an ALS truck or CCT with an ALS provider to watch our patient because that is the level of care the physician has determined the patient to be, that is the level of care we expect to get. To switch to a lower level provider, while the facility or the patient is being billed for ALS, is fraud...plain and simple. We don't expect the Paramedic to just be in the truck. We expect that Paramedic to be attending to the patient. This is one very easy way to lose an IFT contract and get a Medicare investigation as well as a visit from the State office. Is this why you refer to your service as "quasi-Critical Care"?

no...i refer to it as "quasi-critical care" because there is no distinction, short of atlanta or mcg, between emt-p or cct. you can take the classes, however the medic cannot operate in that capacity without a nurse or other clinician assisting, unless the service has found a doctor willing to sign off on the advanced skill set, and there just aren't many of those in georgia.

here is how it works, not that this is the point AT ALL...

facility calls us
we respond to the scene
when we get there, if the call appears to be als, we handle and bill it appropriately
if it's determined to be bls, we handle and bill it as bls
plain and simple

we don't have a complex dispatching system with full patient information yada, yada. we have a dispatcher with no medical training, pen, and paper. the person making the call is barely more educated than the dispatcher, usually a secretary. they do not call and request a certain type of ambulance, we only have one type, as is the case with most services in georgia, though there are a few exceptions in some rural counties. we do not run strictly "bls" trucks, in that there is supposed to be a paramedic on every truck. all of our trucks are fully equipped als units, in that the state inspected them, looked for the appropriate equipment, and said "this is an ALS ambulance." we aren't supposed to have bls units in that there is no running out of the station with a firefighter and an emt. that just doesn't cut it. we don't have first responders. we are strictly an interhospital, interfacility transfer service. we do not set foot into homes. on occasion, we will stumble across a call that would have been better handled by 911 in that they often can get a unit available fast because there is a fairly good chance all of our units are out of town. the facility barely knows what an ambulance is in most cases, much less knowing enough to ask for a specific type of ambulance. do you know how many times i have been asked by nurses and doctors if we carry oxygen? or how many patients have asked when the meal service will be? this is what we deal with 99.999% of the time. occasionally, someone will know enough to request a certain piece of equipment, but generally, they have no clue.

the one exception to this rule is when there is a neonatal situation, in which case, the receiving hospital sends a specialized unit with a four-five person crew.

i don't know what state you are in, or what locale of what state, but in the various areas in which i have worked, people are not educated about ems. they still call us the "sick wagon" most of the time.

before you go throwing "fraud" around, you need to know what you are talking about. number one, this wasn't the point of this thread, and number two, i don't own this ambulance company. if they do it differently some place else, great. i have no control over it. all i can say is that i will never put my patient in harm's way. all i was asking was how to handle the situation appropriately so that the least amount of damage to a friendship and partnership could be done. what i do know is that, as far as i know, there is no fraud. i have always filled out my billing tickets appropriately, for the appropriate type of call.

 

[VentMedic]

do you know how many times i have been asked by nurses and doctors if we carry oxygen? or how many patients have asked when the meal service will be? this is what we deal with 99.999% of the time. occasionally, someone will know enough to request a certain piece of equipment, but generally, they have no clue.

No, they have a clue. It is just that they have many different types of patient transport companies that move patients from point A to point B and some use the same company name.

There is NO WAY you would be allowed to take one of our ICU patients as "BLS" if we stated that patient is to be monitored with a provider who is qualified for ALS. As well, for any ED transfer to another facility there are EMTALA guidelines to be followed.

before you go throwing "fraud" around, you need to know what you are talking about. number one, this wasn't the point of this thread, and number two, i don't own this ambulance company. if they do it differently some place else, great. i have no control over it.

It is difficult to offer warm and fuzzy advice when you are saying your service is one thing but provides something else because you don't want to assume your responsibility as a Paramedic and tell your EMT to drive when you have a serious patient in the back. YOU do have control over this. Others have already offered you advice but it is difficult to play the role of "Dear Abby" and ignor the professional issues.

on occasion, we will stumble across a call that would have been better handled by 911

You are a Paramedic that provides ALS and "quasi-critical care" transport. Why would you need a 911 Paramedic? Do you not have any protocols for emergencies as a Paramedic? In fact, yours should trump the level provided by most 911 services.

i don't know what state you are in, or what locale of what state, but in the various areas in which i have worked, people are not educated about ems. they still call us the "sick wagon" most of the time.

I am hoping you are in the United States because that is how I a basing my explanation.

People do know what EMS is. They just don't know who all the players are or what purpose each truck serves since some call themselves "quasi-critical care". As well, we have FDs, PDs, County, City and Private ambulances, both paid and volunteer, all providing EMS. Add this to the more than 50 different names for EMT providers in the U.S. and most in EMS don't understand it. Some can't even figure out what test and how to for their own state. There are states with as many as 8 different levels of EMS providers. Each state, each county, each city and each service in that city may use a different level provider with different protocols. You also have the "first responder" running around with an O2 tank in the backseat of their car claiming to be part of this mess. We further confuse things by calling the vehicle by various names; truck, ALS Engine, ALS Ladder, bus, ambulance, taxi etc.

Now tell me, is there a menu or a playbill such as those handed out in the theaters so the public or hospital staff knows exactly who is playing the role of what on which stage or transport vehicle?

 

[paragod]

you know what man, this is pointless. i have explained to you over and over and you are like a broken record coming back with the same old crap. i thought this forum was for people with everyday issues in ems. i would think that partner issues fall under that criteria. i'm sorry if i have mistaken this for dear abby. actually, the people with constructive advice were very helpful. i choose to respond to you because you clearly are an authority on this particular subject i was not talking about and didn't bring up.

we are in a small town. we are in a town in which the county is more interested in putting out fires than running patients to hospitals where they can get treatment matching their needs. if our experience or training trumps theres, or whether it should or not, matters not. we run two trucks. at any one time, one or both of these trucks may be as far asfive hours away. that is how this thing rolls. you can't even begin to tell me how things are here. you don't know the people. you don't know what they know. i have my own experiences, and i am relaying them to you.

i do not own this service.

i do not have any interest in defending it against a faceless person on a message board.

i come in. i do my job. i go home. every two weeks i get my bag of peanuts which allows me to live a comfortable life. i don't set the rules, negotiate the contracts, or set emtala policy. i do not roll out with an emt-i in the back with a critical patient. i am not aware of anyone else doing this, either. i advise you to look at my explanation for "quasi critical care" since you love to mention it. go ahead and choose on of the many responses i have had for that. it isn't a company motto. it was me trying to put the service in some kind of context.

if this forum is only for als-bls debates, and how they should be or monday morning quarterbacking, then screw it. because it's just not important in this context. i never said i turned over als calls to my emt partner. i said time-sensitive which was referring to something totally unrelated to the level of care which was required and NEVER, repeat NEVER requested by ANY of our facilities, NONE of which is germane to the orignal post.

but, apparently you know better. apparently there is another transport service here with the same name, same phone number, same staff, even though there isn't anything even close to that here, muddying the waters by offering food, beverages, and lacking oxygen. i see now how the staff can be confused. okay, i don't really, but hey, i'll take your word for it. i'll make sure to pass your warm and fuzzy advice to all of the other pd's, fd's, ems (county city and private), and first responders, even though all but two of those are non-existent in like 90% of the state, much less my city. but you know it all, right? so i'll just call the non-quasi critical care ambulance next time a call comes in. the only problem is which way from "quasi" do i go for? do i go with less quasi or more quasi? because i would hate to defraud you by calling the wrong quasi ambulance. perhaps the hospital staff, you know, the ones confusing us with the pd ems of the same name serving food and lacking oxygen, can determine which level of quasi-ness to choose.

gimme a break!