Paramedic Incompetence Question

[AMF]

Background:
I work for a QRS, meaning we don't transport. When we get dispatched, the neighboring ALS service, which usually runs double paramedic, gets dispatched as well. This service is one of the best in North America; I did my basic ride time with them and have nothing but the utmost respect for them.

Scenario:
I'm running secondary on a call for an intox male in need of evaluation. We get there and the scene is covered in urine (the entire dorm room). Security found the patient in "kowtow" and brought him up against the bed (violating c-spine) to try to wake him before we got there. Bystanders report that the patient was found in the "kowtow" position by his bed, 3' to 4' feet off the ground. Patient presents with a laceration on his forehead several cm in diameter. He is A&Ox0 with a GCS of 9 (5 Motor, barely; 2 Vocal, barely; 2 Pupilary, but fighting it) and has bilateral but slow reaction of pupils to light.
Paramedics get on scene as we discuss boarding him. The primary paramedic is apathetic ("sure, whatever") but insists that he's not carrying the patient.

Question:
I know he's in the wrong about boarding him; I'm not really asking about that. But my partner then says, in essence, "Obviously you out rank us, but we'd really like to board him." Is that true? I've always treated the paramedics as ALS intercepts. They're not part of our service, so the patient isn't theirs until we transfer care.

To reiterate, nothing against paramedics. Most of the ones I interact with are PIFTs with college degrees. They are well-experienced and use expensive procedures sparingly and don't mess up.

 

[Handsome Robb]

I'm not sure if I understand the question. Are you asking if it was appropriate to question the medic or if it is you're patient until you hand them off?

As long as the question is worded tactfully I don't see any reason why it would be inappropriate.

As for whose patient they are once ALS is on scene he is "theirs" so to speak. The medic on scene is the medical authority and ultimately responsible for care of the patient. If they don't want to board him they don't have to. Document it in your chart along with the efforts you made to argue your case to them.

Personally I'd be on the fence for boarding this patient but at this point you're going to be bound by protocol.

 

[AMF]

Why would you be on the fence? He has a questionably significant mechanism of injury to the cervical spine and is incompetent. In Maine, that means he can't be ruled out of spinal immobilization. What would you consider the baseline indication for spinal immobilization?

So we could/have to just leave the patient with them?

 

[Shishkabob]

I'll preface this post with saying follow your agencies guidelines.




Then I'll say once the Paramedic has made patient contact, it's 'their' patient until they say otherwise.

 

[the_negro_puppy]

Why would you be on the fence? He has a questionably significant mechanism of injury to the cervical spine and is incompetent. In Maine, that means he can't be ruled out of spinal immobilisation. What would you consider the baseline indication for spinal immobilisation?

So we could/have to just leave the patient with them?

What is the Kow Tow position?

It is a judgement call about c-spine. Sure you could board and collar him, on the extremely slim chance he has a c-spine or other spinal injury. Once he starts vomiting he is going to be much more difficult to manage, let alone if he tolerates being immobilised.

But to err on the side of caution if he is ALOC, with a mechanism present and unable to be properly assessed due to intox, immobilising would be the safer route.

Don't forget that airway takes precedence over c-spine. If the security left him in an awkward position and he starts vomiting, then what?

 

[Handsome Robb]

I don't know your SOPs or protocols that cover your interactions with them so I won't/can't give you advice on that one, sorry. What I will say is with no transport capabilities you don't have much of a choice now do you?

He really doesn't have a significant MOI, a 3 foot fall is not significant. If we boarded and collared every single drunk who took a digger we wouldn't have enough c-spine gear after a couple hours on certain shifts where I work. I'll go a step further and ask if you if you'd board every Nana who fell down and bumped her head?

 

[Shishkabob]

And while I'm not a fan of it... an altered (and potentially drunk) patient, with a head injury will be getting a backboard and c-collar from me.


I have yet to see field clearance protocols from any agency that let's you withhold a backboard from an altered head injury patient short of fighting them on.

 

[lightsandsirens5]

I'll preface this post with saying follow your agencies guidelines.




Then I'll say once the Paramedic has made patient contact, it's 'their' patient until they say otherwise.

Second that.

I even operated under that principle when I was working as in Intermediate. If I "wanted" a patient from a basic, I took over, regardless of weather they were "ready" to transfer care. I see it as "Me: Higher level of care...therefore...my call...therefore...my scene and my patient."

 

[Shishkabob]

"Me: Higher level of care...therefore...my call...therefore...my scene and my patient."

"Therefor, my certification on the line if something goes wrong, therefor my job, therefor my livelihood."

 

[Handsome Robb]

And while I'm not a fan of it... an altered (and potentially drunk) patient, with a head injury will be getting a backboard and c-collar from me.


I have yet to see field clearance protocols from any agency that let's you withhold a backboard from an altered head injury patient short of fighting them on.

I will agree with this from a CYA standpoint, but I'm with you I really don't like it.

 

[Aidey]

Are we assuming he fell off the bed?

 

[Handsome Robb]

Are we assuming he fell off the bed?

I think that's where this is headed.

 

[Sasha]

I'm seriously getting into the mind set, you want to make the treatment calls then go to medic school.

word questions nicely and politely but accept the fact you're not in charge.

 

[mycrofft]

What is this "kowtow" position?

If it is on haunches but chest and face are in the rug, how can that be 3-4 feet off thee floor?

Parse and 5=4, follow protocols. Try not to kneel in the urine.

 

[AMF]

Second that.

I even operated under that principle when I was working as in Intermediate. If I "wanted" a patient from a basic, I took over, regardless of weather they were "ready" to transfer care. I see it as "Me: Higher level of care...therefore...my call...therefore...my scene and my patient."

If I respond to a scene as a primary only the patient's physician, my super, and my medical director outrank me. In general, I wouldn't take over a scene until I got a report. Especially if I was giving medication (I don't know if intermediates do that in your jurisdiction).

 

[AMF]

If it is on haunches but chest and face are in the rug, how can that be 3-4 feet off thee floor?

Parse and 5=4, follow protocols. Try not to kneel in the urine.

How do you board someone without kneeling (It filled the room)?

Protocol says:
Uncertain Mechanism of injury?
Acute Stress Reaction ---------> Board
Tenderness or pain on spine --> Board
CMS F'n Test failure -----------> Board
Basic Stroke Test failure ------> Board
Unreliable Patient --------------> Board
Else -----------------------------> Don't Board

He definitely fell. Bystanders (reliable) said he didn't have the laceration/contusion earlier that night. And him being combative wasn't a problem. He could barely keep his eyes open.

I agree that airway is a greater priority. If I were an ALS provider I would have used a blind airway. As it was, I was considering an OPA (but I was just the secondary).

I don't see how his fall wasn't at least questionably significant. He fell 4' on his head.

 

[AMF]

I don't know your SOPs or protocols that cover your interactions with them so I won't/can't give you advice on that one, sorry. What I will say is with no transport capabilities you don't have much of a choice now do you?

He really doesn't have a significant MOI, a 3 foot fall is not significant. If we boarded and collared every single drunk who took a digger we wouldn't have enough c-spine gear after a couple hours on certain shifts where I work. I'll go a step further and ask if you if you'd board every Nana who fell down and bumped her head?

I think that was the paramedic's attitude. My thoughts, which you are free to disagree with: If you only get a couple hours off, you only get a couple hours off.

 

[JPINFV]

I think that was the paramedic's attitude. My thoughts, which you are free to disagree with: If you only get a couple hours off, you only get a couple hours off.

What do you mean by a couple hours off? As in down time? As in people who don't c-spine don't do it because they're lazy?

 

[AMF]

What do you mean by a couple hours off? As in down time? As in people who don't c-spine don't do it because they're lazy?

I think that was what the paramedic was thinking. I misread NVRob's post; he seems to be talking about a supply issue, which is not the issue here. It's our board anyways.

I would again ask: what is the baseline indication at your company/region/whoever sets your protocols for spinal immobilization?

 

[Akulahawk]

How do you board someone without kneeling (It filled the room)?

Protocol says:
Uncertain Mechanism of injury?
Acute Stress Reaction ---------> Board
Tenderness or pain on spine --> Board
CMS F'n Test failure -----------> Board
Basic Stroke Test failure ------> Board
Unreliable Patient --------------> Board
Else -----------------------------> Don't Board

He definitely fell. Bystanders (reliable) said he didn't have the laceration/contusion earlier that night. And him being combative wasn't a problem. He could barely keep his eyes open.

I agree that airway is a greater priority. If I were an ALS provider I would have used a blind airway. As it was, I was considering an OPA (but I was just the secondary).

I don't see how his fall wasn't at least questionably significant. He fell 4' on his head.

IMHO, the answer is simple. You follow your protocols. If the primary decides not to follow protocol, you document it and let the primary take the consequences. If this patient can't protect his own airway, I'd consider intubation as well, but I'd want to use an actual ETT instead of a KT, Combitube, or LMA. If you think that the patient needs that advanced airway, doing an airway assessment might be a BIG priority...

When I as a paramedic, arrive on-scene, normally I want to get to the report and begin my assessment immediately. If a lower level provider does not want to give up care and I think the patient can benefit from a paramedic, I will take over. That could mean calling law enforcement to have that lower level provider ejected from my scene. Now if a lower level provider is appropriate to provide care, I will do my assessment and triage the patient back to the lower level provider. My documentation will reflect that.

If that lower level provider does not want to take care back from me, I am stuck with the patient.

There are very few times that I would steam roll over another provider. And there are very few times that I've ever had to do it. Those times that I have, it has always been a lower level provider that was not providing appropriate care.

If the other provider is at the same level as I am, I have to get medical control online to provide guidance. Fortunately have never had to do that.