Need For Definitive Care

[Sasha]

Okay. I may have to eat my words a little, but I feel this illustrates even further the need for 100% ALS, even IFT wise, BUT.

Today on a clinical we had a patient brought in for pulmonary edema. The patient has a pulse of 103, temp of 101.2, rales in all fields, AMS, lethargy.

The patient came from a nursing home RIGHT next to the hospital. Literally a two minute drive and half of that is due to the fact you have to make a U-turn. The patient was brought in by an IFT company.

Initially the patient had a BLS response for "chest congestion" to that patient, the BLS crew assessed the patient and turned down the call for one fo their ALS units to come and pick the patient up. The ALS unit will take about an hour. The nursing home wouldn't call 911. Per nursing home staff's relay to the ALS unit, confirmed by the family, the BLS unit wouldn't take the patient because they didn't want to look like an idiot from bringing in an ALS patient on a BLS truck.

Now. Keep in mind the nursing home is two minutes away from the ER.

Upon arrival this patient was put intubated and put on a vent.

The doctor was furious. Actually called up the company.

Now for all you nurses and RRTs, med students, all you hospital folk, would you prefer a BLS crew recognize the need for definitive care over field intervention and get the patient to the hospital? Would you think less of the crew for transporting?

EMT's, would you have called for ALS and left or transported stat?

I was disappointed while discussing it with fellow students that most would have waited for the ALS unit. One said he didn't want to lose his license. Can you lose your license for a situation like this, transporting an ALS patient BLS?

 

[redcrossemt]

Sasha, you've got it right.

Documentation is always the key to not using your license. After you write up your IPS/whatever, you should document something like "Decided to transport pt after ALS requested and dispatch informed us they were 60 minutes out. Hospital approximately 2 minutes away." You'd be much more at risk for losing your license for letting the patient get an hour closer to death.

From the hospital ER/ICU experience point of view, TRANSPORT! Making this patient wait so the crew doesn't look silly is detrimental to the patient. If you are really worried about looking silly, let ALS tell us the story about how the stupid basic crew let the patient suffer for an extra hour. If we ask why ALS didn't transport, tell us they would have taken longer than the time it took you to get the patient here.

From my experience on a basic truck, TRANSPORT! I would absolutely transport if the ALS crew would take longer to arrive (or intercept) than it would take to get to the hospital (that obviously provides ALS). If you wait for the medic truck, you are actually delaying ALS care to this patient!

 

[Shishkabob]

Anyone that says wait for ALS would be wrong, simple as that.

If the situation is that dire, you are that close to the ED, and ALS is that far away, you do far more harm waiting for ALS.


I say just transport ASAP on BLS. There isn't a damn thing you can do in the 2 minute drive to the hospital that would change their condition.



But thats going off the info you gave only.

 

[JPINFV]

I was disappointed while discussing it with fellow students that most would have waited for the ALS unit. One said he didn't want to lose his license. Can you lose your license for a situation like this, transporting an ALS patient BLS?

There's a reason I used to keep a copy of the protocol I'm linking to in my clip board. Yes, I have left copies of it for RNs who got upset at me for not calling paramedics in a similar situation. Working as a basic, my goal is to get my patient to advanced care as soon as possible, be that advance care from paramedics or an emergency room.

First responding BLS units may transport unstable medical cases to the nearest [paramedic receiving center], while providing appropriate BLS interventions, if the estimated time for ALS arrival exceeds BLS transport time to the PRC.

http://ochealthinfo.com/docs/medical/ems/treatment_guidelines/i40.pdf
Page 2.
Note: It's been slightly reworded since I've left. There did not used to be a reporting requirement or actual criteria for an unstable patient.

 

[VentMedic]

What did this BLS crew for the hour they were with the patient? Could they not have done the same thing in the back of their truck? Do they not have any commonsense protocols for activating 911 themselves or if their ALS is more than 10 minutes away and the hospital is less than 10 minutes, BLS transport? If the patient coded would they have done CPR until their ALS truck arrived or would someone have had the sense to call 911? An AED probably wouldn't have done squat for this patient.

I understand the contracts that some NHs have been forced to initiate with private companies at the insistance of the municipal 911 service but in most of these contracts there is also a clause that if the company fails to perform within the guidelines agreed upon, plan B or C goes into effect.

 

[Sasha]

I understand the contracts that some NHs have been forced to initiate with private companies at the insistance of the municipal 911 service but in most of these contracts there is also a clause that if the company fails to perform within the guidelines agreed upon, plan B or C goes into effect.

I was under the impression nursing homes can't call 911 without orders from a doctor.

 

[daedalus]

Tell the crew to pick up their own cell phone and dial 911 themselves. I have done it many times. Or, transport the patient to the ER. This is a no-brainer.

 

[Shishkabob]

I was under the impression nursing homes can't call 911 without orders from a doctor.

I guess it depends on the NH, as in Dallas they have contracts with AMR, while in Ft Worth, they just dial 911.

 

[Hockey]

Here, if you are <5 mins from the hospital, protocol does not require you to contact ALS. In fact, I was 3 mins from the hospital yesterday, had an overdose that went unconscious, and ALS was 4 minutes the other way. I transported P-1 BLS

Wasn't second guessed. Put in the report that per protocol, <5 mins from nearest hospital

 

[VentMedic]

I was under the impression nursing homes can't call 911 without orders from a doctor.

That is not always the case. Often it is due to the contracts they have entered with the private and municipal services. Some cities/counties encourage the contracts while others try to fight it.

Before it is an emergent emergency, the NH should call the doctor to get transfer orders. Once it becomes immediately life threatening, that usually goes out the window.

Example:
http://www.boston.com/news/local/ma.../05/27/firefighters_sue_over_ambulance_rules/

 

[spisco85]

As a basic that disgusts me. Common sense says get the patient to the hospital. They did assessment and realized they couldn't do much for the patient themselves and I give them props for that but they went from being smart to altered mental themselves when they just sat there.

In the past two weeks I have transported patient's out of the same nursing home that we determined needed ALS intervention. (my partner is an intermediate but in CT that just means IVs) We load that patient and start enroute to the hospital on a priority 1 and call for an intercept. No problems and the patient got to the hospital faster than us saying "well she/he needs a paramedic call and get an ALS rig here"

 

[JPINFV]

Tell the crew to pick up their own cell phone and dial 911 themselves. I have done it many times. Or, transport the patient to the ER. This is a no-brainer.

Meh I just ask to borrow the phone so I can use e911. The SNF won't know that I called 911 until its already dialed.

 

[TiCo]

Wouldn't a quick phone call to the hospital solved the problem? The medical director could give permission for the BLS unit to transport the patient, right? Or the doctor on call?

 

[JPINFV]

^
A situation like this is so basic (no pun intended) that if you need online control for this decision then you should lose your certification.

 

[Epi-do]

While still working as a basic, we were always expected to transport a critical patient if we were closer to the ER than to an ALS unit. It rarely happened, but on occassion it would. Typically, you would hear the BLS unit call the hospital and let them know what they were bringing in. When getting to the ER, if asked why certain things were not done, we would just tell them that we were BLS and that we were closer to the ER than to ALS. The ER's were usually pretty cool about it, and would much rather have you get the patient to definative/advanced care than wait for the medics to show up.

On a side note, but sort of similar, I was taking a difficulty breathing patient in the other night that wasn't moving much air at all. Breath sounds were diminished with very faint wheezes. We got the patient into the truck and headed to the ER. The patient didn't respond to the albuterol and continued to get worse so I ended up bagging the albuterol in for her. I had my partner give the ER a short report to give them a heads up. When we got there, they asked me if I had gotten a line on her. I told them that I was by myself and since I ended up needing to assist ventilations I didn't get anything else done. They were completely ok with it.

 

[medic417]

I was under the impression nursing homes can't call 911 without orders from a doctor.

Yes they can call 911, but it costs more. Nursing homes establish prices with transfer services for much less than a 911 transfer. So it is about the money not the patient or the law.

 

[emtfarva]

Wtf

If I was working Chair Car I would have brought this PT to the Hosp. Ok maybe not if I was working CC. I had a Pt one night that was in resp. distress. This was from a SNF. I walked into the room and asked my partner to call for ALS. I didn't even talk to the Pt and I already was asking for ALS. I was even teching the call and I asked for ALS. At the Pt's side I placed her onto a NRB and attempted a pulse ox. I couldn't get one. We found out that there was no Als. Transfered the Pt to Stretcher and transported to ambulance. GOT a B/P of 50 SYSTOLIC. We transported to the Hosp approx 1 min away. called it a P2, should have been a 1. Got to the hosp and the Pt was put on bi-pap. I was told that Als would have to come from the other side of the city, I DIDN'T WAIT, I TRANSPORTED. THAT IS WHAT THE CREW SHOULD HAVE DONE FROM THE OP.

 

[marineman]

Working as a basic there is no such thing as waiting for "ALS". If it's a priority patient I sometimes won't even call for ALS until we're loaded and en route depending on exactly how rapidly this move needs to be made but I never wait for ALS. I'll call for them and gladly let them know where I am and what route I'm taking, then it's up to them to find me and intercept.

The only exception I could possibly see is an extended transport time (>30min transport) where ALS is 10 minutes or less behind you in the opposite direction, in that case they will never catch you (at least not how I drive) but could potentially do something more to stabilize this patient prior to ED arrival.

I now work on an ALS rig and the medics I work with expect any service their intercepting with to do the same thing, "we drive fast, we will catch you, don't delay the patients transport to the hospital" - actual quote from one of my partners a few weeks ago. It's incredibly unfortunate that common sense is such a rarity these days however piss poor protocols and even worse lawyers have a major impact on decisions like this.

 

[CAOX3]

I dont even get it.

 

[CAOX3]

Let me rephrase that its called neglegence.

Unbelievable an ambulance refusing to take a sick person to the hospital.