LA County Fire.....

Chris31

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So here's my dilemma. I've been a 911 responder with a private ambulance company contracted with LA County Fire for over a year now. I've noticed a pervasive practice by Fire EMT's and Medics alike, which has become more common as call volumes increase. Almost every shift now, I catch a firefighter or paramedic "faking vitals" in order to circumvent LA County ALS criteria and ship a patient BLS. Granted these are usually ETOH or Behavioral patients, In a few incidents, its turned out to be a stroke patient or a STEMI. I'm talking about lying about 12-lead results to base when one wasn't even preformed, or glucose readings which are completely false (101 when it was actually 425). I voiced these concerns first to a paramedic on scene when we were asked to ship a stroke patient bls, and was met with instant retaliation by the entire battalion on scene for questioning a paramedic's assessment skills.
Now, I understand the caliber of Southern California private ambulance EMTs can sometimes be lacking, and this can leave fire with a "bad taste in their mouth", but a good assessment is a BLS skill and when it comes to patient care on scene, its a group effort to provide the best care possible for a patient.
I was informed by a fire captain after the fact, that I was out of line for questioning his medic, and that EMT's are NOT to preform assessments because ALS Paramedic assessments are superior, and render EMT assessments obsolete.

Now obviously, I know this to be completely false, but it shows that as far as the internal workings of LA County Fire are concerned, medics can do no wrong. My question to all of you is; how would you address this breakdown of patient care, and most importantly, address Fire faking vitals in the interest of shipping a patient BLS?
 

chaz90

Community Leader
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If you've already mentioned it to the fire medics themselves and their direct supervisors, go higher. Make a paper trail, get names of who you have spoken to, and go up their chain of command. Lying about vitals or procedures that weren't performed is a serious dereliction of duty and deserves to be dealt with severely. Honestly, I'd push up the chain until I got results from someone. You may not be the most popular guy around in the fire service's eyes, but someone has to effect change at some point.
 

gonefishing

Forum Deputy Chief
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So here's my dilemma. I've been a 911 responder with a private ambulance company contracted with LA County Fire for over a year now. I've noticed a pervasive practice by Fire EMT's and Medics alike, which has become more common as call volumes increase. Almost every shift now, I catch a firefighter or paramedic "faking vitals" in order to circumvent LA County ALS criteria and ship a patient BLS. Granted these are usually ETOH or Behavioral patients, In a few incidents, its turned out to be a stroke patient or a STEMI. I'm talking about lying about 12-lead results to base when one wasn't even preformed, or glucose readings which are completely false (101 when it was actually 425). I voiced these concerns first to a paramedic on scene when we were asked to ship a stroke patient bls, and was met with instant retaliation by the entire battalion on scene for questioning a paramedic's assessment skills.
Now, I understand the caliber of Southern California private ambulance EMTs can sometimes be lacking, and this can leave fire with a "bad taste in their mouth", but a good assessment is a BLS skill and when it comes to patient care on scene, its a group effort to provide the best care possible for a patient.
I was informed by a fire captain after the fact, that I was out of line for questioning his medic, and that EMT's are NOT to preform assessments because ALS Paramedic assessments are superior, and render EMT assessments obsolete.

Now obviously, I know this to be completely false, but it shows that as far as the internal workings of LA County Fire are concerned, medics can do no wrong. My question to all of you is; how would you address this breakdown of patient care, and most importantly, address Fire faking vitals in the interest of shipping a patient BLS?
I've witnessed this several times in the ED. Contact LACDHS or the ems office. Like the previous comment before make a paper trail that way no funny business happens. Always remember that could be your loved one or friend on that cot. Most of these guys do it for the bump in pay and could give 2 damns about the patient.
 

titmouse

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Well thats what happens when you have fire medics, most of them hate the ems side of the job but they have to do it because theyre required. The sad part is that in the end the ones that suffer are the patients.
 

gotbeerz001

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While you're at it, write up the crusty burnt-out single role medics which are (at least) a 1:1 trade for a lazy fire medic.

I do not condone short-cutting assessments, but the problem is not limited to FDs. Let's stay on point and agree that poor patient care is the problem regardless of the patch.
 

gotbeerz001

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So let me try to understand the situation:
In LA County, you have both BLS and ALS 911 transport rigs; you are on one of these BLS rigs. First Responders will arrive and do an assessment to determine which level of transport is required. Your claim is that vital signs have been falsified to justify a lower-level transport.

My questions:
Do ALS units take longer to respond than BLS units?

If not shorter scene times, is there some advantage for LACoFD to send the pt with you as opposed to an ALS unit?

Does FD provide you with Field Notes or a "fire sheet" during hand-over?
 

Jim37F

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In addition to the above, use your PCR's to document EVERYTHING. If you have to write in your narrative that you felt the patient should have gone ALS but was only sent BLS, write it. If no 12 lead was done, and you believe it was indicated, Write no 12 lead performed on scene, etc etc etc. Don't just write LACoFD, be specific which squad and engine were on scene with you. Do the same when giving your handover report to the hospital. Tell the nurses exactly why you think the patient should be ALS, what the medics on scene did and did NOT do. Make your official reports to the County FD HQ, your company, and the County EMSA. But in the immediate meantime, care as best you can for the patient you have, don't be afraid to say you need to divert to the SRC/ASC....if you can, learn the phone numbers to the local hospital EDs or even the base station if need be.
 

Jim37F

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So let me try to understand the situation:
In LA County, you have both BLS and ALS 911 transport rigs; you are on one of these BLS rigs. First Responders will arrive and do an assessment to determine which level of transport is required. Your claim is that vital signs have been falsified to justify a lower-level transport.

My questions:
Do ALS units take longer to respond than BLS units?

If not shorter scene times, is there some advantage for LACoFD to send the pt with you as opposed to an ALS unit?

Does FD provide you with Field Notes or a "fire sheet" during hand-over?
LA County Fire does not have any transport capabilities, ALS or BLS. Instead, they respond to medical calls with a fire engine and a squad, with a private company BLS ambulance. The squad is a dual medic ALS unit that has no transport capability. For ALS level calls, a medic off the squad will hop in the back of the ambulance with the EMT and the squad and ambulance will transport to the hospital while the engine goes back into service. For BLS level calls, both engine and squad will go back into service while the BLS ambulance transports.
 

gotbeerz001

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LA County Fire does not have any transport capabilities, ALS or BLS. Instead, they respond to medical calls with a fire engine and a squad, with a private company BLS ambulance. The squad is a dual medic ALS unit that has no transport capability. For ALS level calls, a medic off the squad will hop in the back of the ambulance with the EMT and the squad and ambulance will transport to the hospital while the engine goes back into service. For BLS level calls, both engine and squad will go back into service while the BLS ambulance transports.
Thanks for the info:
The answer, as said above, is documentation.

Start with your PCR as stated above. Include all FD vital signs in the record as PTA followed by your readings en route. Detail your concerns in a factual manner: no BGL at scene; no 12-lead at scene. Avoid documenting any opinions; they will be discounted.

Does your company have a UO (unusual occurrences) process? If so, I would go there next. Document each UO in detail and submit to your company rep. These should include incident number, date, fire crew and a detailed narrative. You would do well to have your language closely follow that of your local protocols so that deficiencies are clear. Keep digital copies for yourself.

My only concern with going right to County EMS is that it jumps so many logical steps. Your employer has a vested interest in BLS units not transporting ALS pts without a medic. If FD is shorting the process and creating a dangerous situation with significant liability potential, your employer is the one that needs to bring this forward.

If you provide enough information and they choose not to do anything, then one of the following is clear:
1. They are choosing to ignore it (find a new employer)
2. You are overreacting.

Going off the farm as a rogue reporter will cause problems for you unless you at least try the path detailed above.
 
OP
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Chris31

Chris31

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Keep in mind, the 911 contract is a lucrative venture for private companies. That being said, LA County Fire has a large say in choosing which companies get the contracts when bidding comes around, based on their experiences with each respective provider. These private companies, mine included, do everything they can to schmooze fire and throw bbq's for on-duty crews, suspend employees on firefighters complaints, and especially, turn a blind eye to fire's transgressions. Our company is well aware of the issues I brought up, as well as a severe lack of professionalism displayed by fire towards us. They even go as far as to encourage us to practice out-of-scope procedures (glucose sticks) at fires request, just to keep them happy. It's a major conflict of interest.
 

gotbeerz001

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Keep in mind, the 911 contract is a lucrative venture for private companies. That being said, LA County Fire has a large say in choosing which companies get the contracts when bidding comes around, based on their experiences with each respective provider. These private companies, mine included, do everything they can to schmooze fire and throw bbq's for on-duty crews, suspend employees on firefighters complaints, and especially, turn a blind eye to fire's transgressions. Our company is well aware of the issues I brought up, as well as a severe lack of professionalism displayed by fire towards us. They even go as far as to encourage us to practice out-of-scope procedures (glucose sticks) at fires request, just to keep them happy. It's a major conflict of interest.
This is why I was saying give them a chance to bring it forward. If you file a complaint without your employer knowing and they find out, you will end up getting fired.
 

CentralCalEMT

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The best advice for saving your own behind if something goes wrong is document, document, document. If it did not happen, it did not happen. If it happened, it happened. Do not lie or cover up for fire. If things go bad, do you think they will cover for you? It is unfortunate to hear you all are still mistreated down there. It sounds like nothing changed from when I left there years ago.

As far as voicing grievances, it is unfortunate that you work in LA county. The issues you expressed above have been happening there for decades. Remember, the sad fact for companies is that the first priority is keeping the fire department happy and the second priority is patient care. It is wrong. I got my start in EMS working in LA County so I know first hand how it is. Probably about a decade ago, when I was an EMT down there, a certain fire department sent a patient with me BLS. He was ETOH and confused. According to fire, other than the intoxication, the only other complaint was the a patient had a 1 inch laceration to his neck which had been bandaged by copious amounts of kerlex prior to my arrival. The patient went unresponsive enroute to the hospital so I diverted to a closer hospital (which happened to be a trauma center), rather than the one requested by the patient's friend. It turns out the patient had 6 STAB WOUNDS to his neck and internal injuries from blunt force trauma. I reported the incident and almost lost my job. I was told that I should have not diverted to the hospital 90 seconds away, but rather pulled over, and called ALS back to reassess the patient. ALS would have been several miles away by then if they even made it back to quarters before another call and we were mere blocks from a level 2 trauma center. My boss went so far to write me up for disobeying a fire department request and stated that even when fire ships a patient BLS we are not to reassess the patient and by doing that I put the patient at risk because a paramedic has more knowledge than me. He said they have a contract to fulfill and need to not make the fire department look bad. Does that type of situation sound familiar to you?

My hat off to you for trying to stand up for the right thing and be a patient advocate. If it becomes unbearable down there, consider a move to a different county. When I became a paramedic, that is exactly what I did. It is a big move, but if you want to work in a system where your partner is a paramedic and your unit has the final say in patient care and patient destination, and BLS fire departments that support you on scene and do not look down on you, consider moving to Kern or Tulare Counties to work.
 

Jim37F

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The best advice for saving your own behind if something goes wrong is document, document, document. If it did not happen, it did not happen. If it happened, it happened. Do not lie or cover up for fire. If things go bad, do you think they will cover for you? It is unfortunate to hear you all are still mistreated down there. It sounds like nothing changed from when I left there years ago.

As far as voicing grievances, it is unfortunate that you work in LA county. The issues you expressed above have been happening there for decades. Remember, the sad fact for companies is that the first priority is keeping the fire department happy and the second priority is patient care. It is wrong. I got my start in EMS working in LA County so I know first hand how it is. Probably about a decade ago, when I was an EMT down there, a certain fire department sent a patient with me BLS. He was ETOH and confused. According to fire, other than the intoxication, the only other complaint was the a patient had a 1 inch laceration to his neck which had been bandaged by copious amounts of kerlex prior to my arrival. The patient went unresponsive enroute to the hospital so I diverted to a closer hospital (which happened to be a trauma center), rather than the one requested by the patient's friend. It turns out the patient had 6 STAB WOUNDS to his neck and internal injuries from blunt force trauma. I reported the incident and almost lost my job. I was told that I should have not diverted to the hospital 90 seconds away, but rather pulled over, and called ALS back to reassess the patient. ALS would have been several miles away by then if they even made it back to quarters before another call and we were mere blocks from a level 2 trauma center. My boss went so far to write me up for disobeying a fire department request and stated that even when fire ships a patient BLS we are not to reassess the patient and by doing that I put the patient at risk because a paramedic has more knowledge than me. He said they have a contract to fulfill and need to not make the fire department look bad. Does that type of situation sound familiar to you?

My hat off to you for trying to stand up for the right thing and be a patient advocate. If it becomes unbearable down there, consider a move to a different county. When I became a paramedic, that is exactly what I did. It is a big move, but if you want to work in a system where your partner is a paramedic and your unit has the final say in patient care and patient destination, and BLS fire departments that support you on scene and do not look down on you, consider moving to Kern or Tulare Counties to work.
I just want to reiterate the document, document, document part.

As far as me personally being an EMT in LA County...I'm so glad I work directly for a department as an AO...means instead of a street corner post following the call I go back to the station where my medics are, and after only a couple months have gotten to know most of the crews I work and run calls with, meaning they pretty much trust us to run a BLS assessment as needed. And if there's ever any issues that come up I have an EMS Captain and an EMS Battalion Chief I can go to which should carry just a bit more weight than a private company supervisor when dealing with the occasional arrogant prick paragod (unfortunately even we're not immune to having one or two running around).

If I was allowed to make one single change it would be to put the private ambulances in the same stations as the squads they run with.

Either that or have the ambulances be medic/basic so even if fire insists it's BLS and they leave there's still a medic available if the EMT isn't quite comfortable running the call themselves.
 

DrankTheKoolaid

Forum Deputy Chief
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Ah the reason California has such crappy protocols..... The ever famous LAFD..

Nothing like a fire Union to sweep crap under the rug and cover for sub standard practitioners.

Yes I understand most did not go into the fire service to become medics and EMTs, but guess what due to the absolutely excellent fire prevention people FF are 95% or greater medical responders and 5% dumpster firefighters.


My rural brethren excluded....
 

socalmedic

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As others have said, it hasn't changed much in the 7 years since I left. I had been sent BLS on patients with multi-system trauma, penetrating trauma to the trunk, chest pain that ended up being STEMI.... you name it and LAclownyFire has sent it BLS. I now work as a paramedic in a neighboring county near the border and every other day or so the BLS provider rolls in with an ALS patient and no paramedics. The hospital here is not okay with how LAcoFD operates and the Pre-Hospital Lesion Nurse filed numerous reports with not only their BC/EMS division, but the base hospital who is their med control, and the county EMS agency with no apparently no changes (this is not to say nobody was disciplined or addressed as we dont get that information).

my suggestion is to document in your PCR, and your own record because somehow when the poop flies even ePCRs "get lost". document only factual observations, opinions can discount your entire report. Email your reports, use the EMS Sequence number not the patient name, to the base hospital paramedic lesion nurse, the medical control physician for their base (you can look them up on the LAEMS website), and CC the EMS agency (call them to find out who their CQI person is) request a confirmation that they received the notification.

here is the policy MANDATING at 3 day reporting window for the PCC. (policy 214)
http://file.lacounty.gov/dhs/cms1_206170.pdf

further you can contact their investigator directly
Kurt Kunkel
Civilian Investigator
(562) 347-1687
(562) 941-5835 (FAX)KKunkel@dhs.lacounty.gov

he is the person who posted the thread to the "anonymous" reporting line. It appears that he is more interested in company violations for all the BLS companies in the county, but he could probably put you in touch with the right person to report issues of ethics and patient care. just remember that CPF or IAFF gets involved when any fire fighter is disciplined and once they get the report you will not by anonymous anymore because the firefighter has the right to face his accuser.

I hope everything gets better in LA sooner rather than later, because it has been going downhill for years.
 
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COtoWestAfricaMEDIC

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How come southern cali has not had the big earthquake, and floated off in in the sea away from the US and down to Mexico. The EMS system in southern cali belongs in Mexico City or wait there's might be better.
 
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Tigger

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In addition to the above, use your PCR's to document EVERYTHING. If you have to write in your narrative that you felt the patient should have gone ALS but was only sent BLS, write it. If no 12 lead was done, and you believe it was indicated, Write no 12 lead performed on scene, etc etc etc. Don't just write LACoFD, be specific which squad and engine were on scene with you. Do the same when giving your handover report to the hospital. Tell the nurses exactly why you think the patient should be ALS, what the medics on scene did and did NOT do. Make your official reports to the County FD HQ, your company, and the County EMSA. But in the immediate meantime, care as best you can for the patient you have, don't be afraid to say you need to divert to the SRC/ASC....if you can, learn the phone numbers to the local hospital EDs or even the base station if need be.

You're PCR is not the place to discuss which treatments you feel should or should not have been performed. PCRs are a record of the care provided, and that it's it. If there is a problem on a call it should be documented on an incident report, not a patient's medical record.
 

socalmedic

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You're PCR is not the place to discuss which treatments you feel should or should not have been performed. PCRs are a record of the care provided, and that it's it. If there is a problem on a call it should be documented on an incident report, not a patient's medical record.
I respectfully disagree. firstly, the BLS report in LA County does not get attached to the patients chart; the report from the ALS agency is taken with the patient (they are still using paper carbon copies) and it is placed in the chart. the BLS PCR is used for billing. Secondly, documenting discrepancies is a vital part of the health record. physicians and nurses document discrepancies all the time which is useful for the final provider to discern validity of findings. as a permanent and official record the PCR is how investigators will determine what actually happened. it should be noted that 12-leads are not transmitted in LA county, printed 12-leads are only collected on patients transported as ALS and even then rarely make it into the patient chart if it wasn't a STEMI. lets look at a case example:

55 year old female C/O Chest pain calls 911. ALS decides this isnt a "real chest pain" and decide this is bls with no BGL or 12 lead. patient has a Hx of angina, diabetes, and peripheral neuropathy. ALS makes base contact because they need approval to send this as BLS and report exertional pain in the shoulder, BGL 120 mg/dl, and a - 12-lead. the BLS provider was on scene for the entire assessment and knows that there was no BGL check and no 12 lead performed. when you get to the non-PCI hospital they find a bgl of 400 mg/dl and a STEMI on 12-Lead. they have to keep the patient for an hour until a CCT ambulance arrives to transport the patient 5 min away to the PCI hospital. the patient dies and the family sues.

-if the emts dont document in the PCR what they actually saw the only records will be the falsified ALS report and the hospitals charts. because the ALS report shows that the assessment was done correctly it will be chalked up to an "evolving MI" and that will be the end of the investigation.
-if the emts do document that they witnessed no 12-lead and no BGL check, and they were on scene the entire time ALS was there will be an investigation as to what is correct. if the investigation moves quick enough the investigator can download the memory from the monitor and verify if there was ever a 12-lead done at the date and time in question, and check the glucometer to see if there is a record for a BGL at the date and time in question. given that there is a requirement to report adverse outcomes within 72 hours both machines should still have all the data needed still in the memory.
 

triemal04

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You're PCR is not the place to discuss which treatments you feel should or should not have been performed. PCRs are a record of the care provided, and that it's it. If there is a problem on a call it should be documented on an incident report, not a patient's medical record.
It isn't the place to mention what you thought should have been done...most of the time.

If an EMT requests that an eval be done by a paramedic, and is refused, either by the paramedic, or by another EMT who is in overall charge, that should definetly be documented. That's more than appropriate, if only for CYA purposes, and there's nothing wrong with putting it in the chart; makes it clear to anyone down the road in the hosptial what was/wasn't done.

Listing things that weren't done...if you know for a fact that something should have been, or was reported to have been done but wasn't, it's still appropriate to document that as well. Just be sure that you aren't listing things that weren't indicated; the only effect will be to make you look silly.
 

MonkeyArrow

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I agree with documenting the lack of appropriate care in the PCR. As an EMS provider in the field, that is the only protection you have against erroneous claims or lawsuits. What do you think the first thing a lawyer is going to say in court when he is suing you for malpractice? "If you had thoughts that this patient did not need to go BLS, why is there no record of this? Are you now lying or were you negligent in the care of this patent." If you're getting screwed over, you do what you need to do save your butt. If that means you document what has happened/did not happen in the PCR, then you do so. At the end of the day, it is your license to practice on the line.
 
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