Need For Definitive Care

[Sasha]

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/

From my very limited experience... Once an emergency becomes immediatly life threatning the nursing home can't seem to find the "11" key.

It's unfortunate the patient had to suffer. I'm wondering though if the hour would have made a difference and kept the patient from being tubed. Either way, Critical Thinking should be a pre-req for an EMT class. It's amazing how far some basics/medics will go to justify refusing to think about the bigger picture and not just the next 10-20 minutes of patient care.

 

[BLSBoy]

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.

Before I jump down your throat with both feet, I am going to let you explain this statement.

 

[BLSBoy]

Sasha, I am going to go out on a limb, and guess that the agencies ambulances were white, with slime lime graphics, and are in the process of getting the boot from Orange County, and Orlando for the same types of actions?

If I were the MD, I would be hunting for those 2 EMT's heads.

Brainless dolts are about the only words I can come up with to describe them.

 

[Foxbat]

Before I jump down your throat with both feet, I am going to let you explain this statement.

I don't know your or marineman's local protocols... But our state says:
"If transport time by BLS to an appropriate receiving facility can be accomplished before ALS can initiate care, then the BLS service should transport as soon as possible and should not request or should cancel ALS; BLS services should not delay patient care and transport while waiting for ALS personnel. If ALS arrival at scene is not anticipated before initiation of transport, arrangements should be made to rendevouz with the ALS service".

The exception protocols make is for long transports with ALS coming from opposite direction, if waiting for ALS for a short time will significantly decrease time to ALS care. Otherwise, it's what marineman said.

 

[TransportJockey]

I've had patients like that when I worked an IFT truck. I would get them loaded, support w/ BLS skills (although in NM that includes combitube and narcan, great for duragesic patch overdoses), and transport code to the ED. We had one SNF that was literally right across the street from an ED, so I've done this type of scenario before.

 

[VentMedic]

From my very limited experience... Once an emergency becomes immediatly life threatning the nursing home can't seem to find the "11" key.

You will probably never get the butt chewing these nurses get many times a week from the doctors, owners of the NHs, families and the EMT(P)s. Even in our SNF I have walked in on an EMT screaming in the face of a nurse half the EMT's size because the paperwork was not immediately prepared like it was supposed to be. That was on a routine transfer. There is little wonder why NHs can not keep good nurses. Those with the patient's interest at heart will find it a daily struggle. They are danged if they do and danged if they don't. With their license and title comes a crap load of responsibility that is not worth the money NHs pay RNs or even LVNs.

As for the EMTs in this situation, if they were clueless, why did they not call a field supervisor or anyone for advice? They also had the option of calling 911 themselves even if their company would lose the fee. Just like your statement I quoted above, they had no thought process going on for the greater good of the patient.

 

[Sasha]

Sasha, I am going to go out on a limb, and guess that the agencies ambulances were white, with slime lime graphics, and are in the process of getting the boot from Orange County, and Orlando for the same types of actions?

Negative. The agencies ambulance were blue and white and are in the process of helping the lime graphic company out of the area by taking all their contracts.

 

[Sasha]

Even in our SNF I have walked in on an EMT screaming in the face of a nurse half the EMT's size because the paperwork was not immediately prepared like it was supposed to be.

I've seen that before too, and been the partner going "I'm so sorry!" once the yeller had stormed off. It's terrible, there's never a place to yell, but on the flip side not every nurse is so innocent, and scream at the IFT EMTs/Medics for being late when they had just gotten paged for that call 5 minutes prior and had been running around three different counties. There is a HUGE Us Vs. Them.

Nursing home nurses have a tough job, I have the utmost respect for MOST of them, it has to be overwhelming to have that many patients at once all day every day. But then I run into nurses that kind of spoil the whole bunch.. I've gone to pick up a patient and have the nurse tell me that the patient has no DNR and she's not even sure if the patient is still alive.

But my comment was inapprorpriate, I apologize. It was late (or very early.) and I wasn't thinking clearly.

 

[JPINFV]

Even in our SNF I have walked in on an EMT screaming in the face of a nurse half the EMT's size because the paperwork was not immediately prepared like it was supposed to be. That was on a routine transfer.

[tone of disbelief and bewilderment]
That won't happen on my ambulance. I'd be on the phone with the crew chief so fast it wouldn't even be funny. Oh noes, the paperwork isn't ready? Then package the damn patient and take a 5 minute break and calm the F down. [/tone]

I weep sometimes for the state of EMS in this country.

 

[mikeN]

I've had a few similar calls like this recently and I requested ALS and never got them. We didn't even think to wait. Load and go. If I waited like that I'd probably get fired. then again I work in the Boston area where you can through a rock and hit 2 or 3 hospitals, so hospital transport times are super short and getting ALS is a longer than the transport.

 

[VentMedic]

[tone of disbelief and bewilderment]
That won't happen on my ambulance. I'd be on the phone with the crew chief so fast it wouldn't even be funny. Oh noes, the paperwork isn't ready? Then package the damn patient and take a 5 minute break and calm the F down. [/tone]

You don't think I didn't make a call? But first I had security and one of our LEOs sit his arse in a room well away from hospital staff and patients.

We've had a few get belligerent in the ED when they don't think they are getting attention fast enough. Since we do have a heavy LEO and security presence there, it doesn't get far. Most know not to start anything with our ED staff. They take enough crap from some of the patients.

When you have as many ambulances in and out of a facility as ours does, the odds are there will be some idiot that doesn't do justice to the uniform. This is not just with the private companies, we have a few FF/medics that could use some anger management classes also. We just don't see the problems as much becasue they will be dressed down quickly by their superiors.

I know you have read some of the angry post toward nurses and even doctors on the forums. A few don't handle people they believe to be inferior giving orders to them. A bad week at home along lack of sleep from 24 or 48 hour shifts and it doesn't take much to set someone off with a short fuse. This profession also attracks strong personalities. I've dumped a few partners during my years in EMS for serious anger problems toward anyone, including the patient and nurses, whom they thought to be just looking at them wrong.

 

[JPINFV]

I know you have read some of the angry post toward nurses and even doctors on the forums.

I don't think it's quite fair to compare something that happens on scene to what goes on on the internet. I'll admit, not all of my interactions with other health care staff has been full of rainbows, flowers, and puppies, but if I need to vent over someone's apparent stupidity, there's always after the call in private or the internet.

 

[VentMedic]

I don't think it's quite fair to compare something that happens on scene to what goes on on the internet. I'll admit, not all of my interactions with other health care staff has been full of rainbows, flowers, and puppies, but if I need to vent over someone's apparent stupidity, there's always after the call in private or the internet.

Not comparing what happens on the internet. I just recognize some of the same angry statements I have heard in this profession and others as well. You pick up on certain key words in conversations especially at scene and start checking your exits.

Stress can create many problems and has many causes. That is why I do not support CISD or some support groups that have no professional leadership. Everybody comes with their own bagage and set of individual problems as well as their own unique wiring.

Right now we have several employees who have been working OT trying to keep their homes from foreclosure and many who have already had their homes foreclosed on. Talk about the stress. Then, in San Francisco, the DOH laid off some healthcare workers and cut the pay of others. In Florida, we have been running stretched very thin for help because the hospital didn't bring in as many travelers for the season. During all this, some on ambulances expect everyone to greet them as if they are the most important person in the world. Yeah, I know this since I used to think that way also. It didn't take long to see another side.

 

[BLSBoy]

I don't know your or marineman's local protocols... But our state says:
"If transport time by BLS to an appropriate receiving facility can be accomplished before ALS can initiate care, then the BLS service should transport as soon as possible and should not request or should cancel ALS; BLS services should not delay patient care and transport while waiting for ALS personnel. If ALS arrival at scene is not anticipated before initiation of transport, arrangements should be made to rendevouz with the ALS service".

The exception protocols make is for long transports with ALS coming from opposite direction, if waiting for ALS for a short time will significantly decrease time to ALS care. Otherwise, it's what marineman said.

I have no issue with the rendezvous thing. I do it all the time.

Its this...

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.

 

[CAOX3]

As for the EMTs in this situation, if they were clueless, why did they not call a field supervisor or anyone for advice? They also had the option of calling 911 themselves even if their company would lose the fee. Just like your statement I quoted above, they had no thought process going on for the greater good of the patient.

I really cant understand this, it seems quite simple to me. Both EMTs should have the certs revoked.

They Failed to provide treatment and transportation to a pt in need.

End of story.

 

[RESQ_5_1]

Not being a Paramedic, as well as having treated PE pts (it actually didn't end well even with ALS intercept), I would like to know what treatments a PAramedic can do for suspected PE. Or, is it just a matter of knowledge to be able to diagnose a PE. My previous partner was actually working his first shift as an EMT-A with me when we got called to a lady who fell off her toilet. So, it got dispatched as a fall with priority response (17-D-1). My partner auscultated lung sounds initially and heard nothing. He was just about to get a BP while I was supporting her from the back (she was sitting on the floor). She stated she was dizzy and slumped back against me. I gently lowered her to supine and my partner started getting a BP while I started getting some O2 ready. Keep in mind, this is all within the first 2-5 minutes on scene. So, we are trying to determine the cause for dizziness which resulted in the nose-dive off the toilet.

Her son was there with us and stated that she wasn't breathing. Checked pulse and there was none. Apparently, pt got dizzy and slumped back due to cardiac arrest. We immediately started CPR and proceeded to move her to the rig. Her son told us (after she coded) that she had been short of breath with occasional dizzy spells for the last 2 weeks since she returned from Australia. We immediately suspected PE from there. And even with a Paramedic and 2 EMT-A's running the code, she was pronounced at the hospital. It was about a 20 min transport time.

Up until she went into cardiac arrest, she had a GCS of 15, A/Ox4, no apparent respiratory distress. We were initially thinking TIA until the son mentioned the trip to Australia.

Are there any other indicators we might have missed?

As far as the BLS crew that didn't transport and waited for ALS, I would rather explain why I felt the need to transport instead of waiting than to explain why I delayed treatment for an hour.

 

[OzAmbo]

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.

Wow, this statement is so incredibly negligent :excl:

YOUR JOB is to bring the best available care to a patient, how you do that varies from service to service and situation to situation, and sometime given constraints it may not be possible and a quick dash to hospital with minimal care may be the best option at the time, but the arrogance of calling ALS after you have loaded and not when you have assessed the pt as needing more advanced intervention is just mind boggling.:wacko:

 

[VentMedic]

RESQ_5_1

This is a good scenario so why don't you copy and paste it to its own thread? That will give the chance for good discussion on assessment and treatment without distracting from Sasha's original post

Not being a Paramedic, as well as having treated PE pts (it actually didn't end well even with ALS intercept), I would like to know what treatments a PAramedic can do for suspected PE. Or, is it just a matter of knowledge to be able to diagnose a PE. My previous partner was actually working his first shift as an EMT-A with me when we got called to a lady who fell off her toilet. So, it got dispatched as a fall with priority response (17-D-1). My partner auscultated lung sounds initially and heard nothing. He was just about to get a BP while I was supporting her from the back (she was sitting on the floor). She stated she was dizzy and slumped back against me. I gently lowered her to supine and my partner started getting a BP while I started getting some O2 ready. Keep in mind, this is all within the first 2-5 minutes on scene. So, we are trying to determine the cause for dizziness which resulted in the nose-dive off the toilet.

Her son was there with us and stated that she wasn't breathing. Checked pulse and there was none. Apparently, pt got dizzy and slumped back due to cardiac arrest. We immediately started CPR and proceeded to move her to the rig. Her son told us (after she coded) that she had been short of breath with occasional dizzy spells for the last 2 weeks since she returned from Australia. We immediately suspected PE from there. And even with a Paramedic and 2 EMT-A's running the code, she was pronounced at the hospital. It was about a 20 min transport time.

Up until she went into cardiac arrest, she had a GCS of 15, A/Ox4, no apparent respiratory distress. We were initially thinking TIA until the son mentioned the trip to Australia.

Are there any other indicators we might have missed?

 

[Aidey]

As much as I would like to lambast the Amb crew for this, when you are a basic it can be hard to argue with someone with more training/education/letters behind their name than you. I definitely think that the BLS crew should have said "eff it" and transported the PT, but I also think some responsibility lies with the NH staff.

I agree with the above sentiments that it can be hit or miss with NH staff. We were called the other day to one of the local NHs for a "flu" patient. They had already transported 6 other patients for "flu" (which turned out to be Norovirus). Anyway, we get there and the lady has ronchi from 10 feet away, was breathing 58 times a min, and cyanotic around the lips and she had 3+ bilat pedal edema.

I was pretty irritated with the NH staff, if they hadn't had the "flu" outbreak how long would they have waited to call for this lady? It's times like that I was to give them a piece of my mind, however I've also been to NHs where the staff was really on top of things and very proactive.

 

[OzAmbo]

As much as I would like to lambast the Amb crew for this, when you are a basic it can be hard to argue with someone with more training/education/letters behind their name than you. I definitely think that the BLS crew should have said "eff it" and transported the PT, but I also think some responsibility lies with the NH staff.

Thats a good point and one i hadn't thought of. Even Paramedics get rubbished into bad decisions every now and then, especially new ones. I occasionally have issues taking over care from another Paramedic, despite not necessrily agreeing with what the other guys treatment plan is, i dont interject until after we have parted ways, then i changed treatment modailities. Someone with a bit more guts about them could come up with a way to "introduce" new insight into the picture instead of just accepting it. Im not perfect, but im learning.

Making a mistake, specially though inexperience or a situation where policy or procedure is ambiguous should not be a sackable offence, identifying the issue and rectifying it is a better answer for all involved. Habitual stuff ups despite rectification show an endemic issue.