Stay-play / Load-go/ Upgrade?

[Shishkabob]

So as you all know, one of the BEST parts of being a brand new medic is always doubting yourself... and tonights has to do with Staying, loading, or upgrading.



It's common consensus that on a BLS truck, if the hospital is closer than the ALS intercept, just transport... but what if ALS intercept is there, but it takes less time to get to the hospital than to do ALS treatment?




Tonight we were dropping a patient off at a psych hospital. As we were calling on, dispatch said "We have a BLS truck at that location with a hypertension call, would you mind sending your medic (me) to go check them out and see if they need help?"


So I go to where the BLS truck crew was, an Intermediate and a Basic. The Basic is just about to finish his paperwork. Quick rundown of the patient--- 40's male, BP of 198/118 hr of 58, headache, nausea (but no vomitting), seems a slight bit lethargic (but unable to tell if that's baseline, it being 2am, medications, or the BP) no CP, no SOB, pupils are fine, lungs clear, no other medical history aside from psych. Nurse states his BP's been elevated since Friday. (Keep in mind this is a generally good psych hospital). They've given Norvasc with little change in BP.



Now comes the question. This psych hospital shares a parking lot with a major hospital. The transport from A to B takes less time than it would take me to set up a 12-lead.




So, considering his condition has been "stable" for atleast 24 hours, and you're literally THAT close to the hospital, what would your decision have been? Stay and treat the BP, let the BLS crew transport, or start some ALS and ride in their rig and go?

 

[Smash]

Why would you treat his BP? Why has the basic been sitting on scene doing paperwork? What are you going to achieve for the patient by doing a 12 lead or other investigations given that you are literally on the doorstep of the hospital?

 

[Shishkabob]

Meh, I don't know why they were sitting on scene for the length they did, and even though I didn't take over the call I hurried them up a bit.... which irked the Intermediate some. His attitude with me made me chuckle afterward.

I was using the 12-lead as an example as to how close we were, not that I had done one.

I chose NOT to treat because A) we WERE so close...I wouldn't have even gotten the supplies for an IV out by the time we would have backed in to the ER. and B ) he has been elevated for a while, so another couple minutes probably wouldn't cause more damage than has been done.



I just let the BLS truck transport, which is why I'm seeing if anyone would have done differently.

 

[Smash]

Meh, I don't know why they were sitting on scene for the length they did, and even though I didn't take over the call I hurried them up a bit.... which irked the Intermediate some. His attitude with me made me chuckle afterward.

I was using the 12-lead as an example as to how close we were, not that I had done one.

I chose NOT to treat because A) we WERE so close...I wouldn't have even gotten the supplies for an IV out by the time we would have backed in to the ER. and B ) he has been elevated for a while, so another couple minutes probably wouldn't cause more damage than has been done.



I just let the BLS truck transport, which is why I'm seeing if anyone would have done differently.

I'm sure someone would do different, but I wouldn't.

 

[FFMedic75]

You did the right thing, treating a patient on scene is generally acceptable if you can provide definitive care, i.e. anaphylaxis. This is not the case here, keep in mind you stated they had already been given a Calcium Channel Blocker with no change. As far as not letting the BLS crew take it, there would probably be nothing different in treatment even if something catastrophic did happen due to the short ETA, but try to imagine defending yourself for turning this patient over to a Basic and finding out this is all caused by a slow Subarachnoid Bleed. Always error on the side of caution and use common sense, that is usually the first thing to go when you get your card. Something I was told when I first got my medic that I will always remember, "If you are trying to talk yourself out of making an intervention you should have already done it." "If you are trying to justify doing something you probably didn't need to do it."

 

[Veneficus]

If I were there, I would have told dispatch to have the BLS squad take him.

he has uncontrolled hypertension, it takes a lot of work to figure out why and what to do about it.

You can't do it on an ALS ambulance.

So what if the pt had a CVA? how does that change anything? I think:

"ladies and gentlemen of the jury, I told the BLS squad to take them to the hospital because they would have gotten better help faster than if I showed up and started a more detailed work up from the begining knowing full well from my education, training, and knowledge of commonly accepted medical practice that I would not been able to help in anywhere near the capacity of the hospital and would have put the patient in greater risk with my efforts."

The scenario doesn't even change if the CC was crushing substernal chest pain radiating to the arm and jaw. By the time you show up, start the workup and treatment, the patient could have been in the ED receiving heparin or starting a STEMI protocol that activates a cath lab.

 

[FFMedic75]

If I were there, I would have told dispatch to have the BLS squad take him.

he has uncontrolled hypertension, it takes a lot of work to figure out why and what to do about it.

You can't do it on an ALS ambulance.

So what if the pt had a CVA? how does that change anything? I think:

"ladies and gentlemen of the jury, I told the BLS squad to take them to the hospital because they would have gotten better help faster than if I showed up and started a more detailed work up from the begining knowing full well from my education, training, and knowledge of commonly accepted medical practice that I would not been able to help in anywhere near the capacity of the hospital and would have put the patient in greater risk with my efforts."

The scenario doesn't even change if the CC was crushing substernal chest pain radiating to the arm and jaw. By the time you show up, start the workup and treatment, the patient could have been in the ED receiving heparin or starting a STEMI protocol that activates a cath lab.

Telling dispatch to go ahead and take them is fine and probably what I would have done, but once you as a medic are on scene with the patient, it is your patient, especially if your standing orders list hypertension as an ALS ride. If he had told dispatch to have the BLS crew transport before arriving on scene that is different.

 

[MasterIntubator]

In my protocols, in clearly states that any hypertensive crisis not presenting with CVA or AMI is to be BLS only. If I were in that spot ( and I have ) I would probably use that as my guide and use common sense from there, just a transport.

Our BLS crew would have been at the ER already.

 

[Veneficus]

Telling dispatch to go ahead and take them is fine and probably what I would have done, but once you as a medic are on scene with the patient, it is your patient, especially if your standing orders list hypertension as an ALS ride. If he had told dispatch to have the BLS crew transport before arriving on scene that is different.

I see what you are getting at, and I m not saying that you are not right, but I disagree.

I think that we both agree that the BLS crew should have just transported. Especially with the phrase "finishing up the paperwork." There was no reason for Linuss to even have patient contact.

But to discuss what I do not agree with. In any system I ever worked in (including the messed up one where the FTOs made up their own rules in contra to the protocols) There is usually a phrase in the protocol book that mentions something about "protocols being guidlines not meant to replace sound clinical judgement."

if a paramedic could never turf a patient, it could create all kinds of issues not only in mass casualty, but with day to day EMS operations. As soon as you looked at the patient, you would be obligated to take them if that is the case.Even if no interventions were done.

If your protocol book does mention that elevated BP is automatically an ALS response or transport, it might be time to exercise the sound clinical judgement when you are a stone's throw from the hospital.

There is also the issue of what "on scene" actually means. If I am on the 11th floor of a hospital, and i need to see a patient on the 3rd floor. My being in the hospital does not mean I am "on scene." Any agency can have multiple calls to a particular address. If there is a room and contents fire in an apartment complex in room 502 and a medical emergency in room 101 with no connection to the fire, then neither responders in any given area are "on scene" of the service request in the other.

I would agree that in this case, once Linuss got to the patient, it would have been less of a gray area to just load up and go without performing anymore assessment or intervention than what could have been done while transporting. I think Linuss was right in there was nothing that he could have done further for the patient an in a round about logic, if there is nothing you can do for a patient that a bls unit can't, then logically, the patient doesn't need you. Then you keep an available medic unit in service and the patient still got everything they should have.

But if there was any failure, I would blame the BLS squad. The initial call should not have been to dispatch, they should have had the situational awareness to either just transport or call med control to get permission to transport. If they were waiting on scene doing paperwork, they were not using sound clinical judgement. Not every situation can even possibly be written into a protocol book.

I would fault the dispatcher for not telling them to just transport. (having been a field guy with absolutely no time or interest in dispatch; an aversion actually) dispatch can always be blamed somehow

again, i don't think either of us are "wrong" just a different perspective.

 

[firecoins]

With a stable patient, I would have done the 12 lead and line. You have to thinl how long it would take to transfer the patient over to ther ED before getting treatment.

THe BLS crew called. I will not 2nd guess them.

 

[Shishkabob]

Eh, it wasn't the BLS crew asking for assistance (that they clearly should have) but dispatch wanting them to be checked up on because of the nature of the call (think of a paramedic fly car and that's the role I was acting in)... should have been an ALS call but dispatch screwed up by sending my unit for a BLS call instead of the BLS truck right next to us.




Apparently on arrival to the ED, just before they whisked him off to CT, his Bp was 258/152.

 

[Too Old To Work]

No IV, no 12 Lead. Point the BLS crew in the direction of the appropriate facility and wave good bye.

 

[gicts]

We don't have intermediates in our state, but couldn't he have started an IV and ran a strip? :wacko:

I think this call should have been well within his knowledge.

 

[Veneficus]

We don't have intermediates in our state, but couldn't he have started an IV and ran a strip? :wacko:

I think this call should have been well within his knowledge.

What is the point of that?

So close to the ED, no matter what was on a strip, when the guy is still awake, the jaunt over to the ED is a better use of time.

Who cares about an IV, with that BP, unless you have labetalol or even better, esmolol, there isn't much that will go in that IV that will help. (if available you could set up a nitro drip) but really why waste time when better things are available next door?

 

[Shishkabob]

We do have Lebetalol... but like 99% of our drugs, only at the Paramedic level.... and sadly it's only for Afib, Aflutter and SVT.

 

[Too Old To Work]

What is the point of that?

So close to the ED, no matter what was on a strip, when the guy is still awake, the jaunt over to the ED is a better use of time.

Who cares about an IV, with that BP, unless you have labetalol or even better, esmolol, there isn't much that will go in that IV that will help. (if available you could set up a nitro drip) but really why waste time when better things are available next door?

I agree completely. This is purely a BLS call. Absent airway problems or unresponsiveness, CVAs are a BLS call for us too, but that's a different story.

 

[rhan101277]

Seems like a slow bleed/CVA to me. It almost fits Cushings Triad, except for him not having irregular respirations.

A embolic stroke fits perfectly though. I think you did right.

 

[CAOX3]

For a BLS point of view.

I would have simply waved you off before you even had the chance to lay eyes on him releasing you from any responsability. Then again I would have already been at the ER, so it wouldnt have been an issue.

 

[JPINFV]

Quick question for the "CVA's are BLS" crowd. Unless BLS can take (either themselves or by facility staff proxy for IFTs) a BGL, how are you expecting BLS to differentiate between hypoglycemia and a CVA?

 

[Too Old To Work]

Quick question for the "CVA's are BLS" crowd. Unless BLS can take (either themselves or by facility staff proxy for IFTs) a BGL, how are you expecting BLS to differentiate between hypoglycemia and a CVA?

Our BLS crews have glucometers for that reason. Of course now they use them for everything, which is stupid. Every drunk passed on out on the sidewalk gets his BG checked. Drives me nuts.

When the only tool you have is a hammer, everything tends to look like a nail. When the only tool you have is a glucometer, everyone tends to look like a hypoglycemic.