Was I wrong?

[lightsandsirens5]

Regardless of whether or not this is ACTUALLY an ALS or BLS call, if the basic provider isn't comfortable, who is the medic to think that he can force the basic into tech-ing the call? That is the biggest issue that I see here.

I don't care if it's a stubbed toe, if the basic isn't comfortable, then the medic gets the call. That is part of the responsibility that comes with that big capital P after your EMT-.

 

[TheLocalMedic]

Almost nobody without underlying pathology can drop their oxygen saturation by voluntarily holding their breath.

^This. But don't forget that there's many things from dirt and grime to cold fingers that can foul up your pulse ox too.

 

[Carlos Danger]

I don't care if it's a stubbed toe, if the basic isn't comfortable, then the medic gets the call. That is part of the responsibility that comes with that big capital P after your EMT-.

Yeah, I don't know about that. Basics have just as much responsibility as medics do to manage transports that fall within their scope.

I don't like to see the "I'm uncomfortable" card played when it's something the uncomfortable party should obviously be able to manage. It means the player of the card is either lazy or clinically weak.

 

[triemal04]

Regardless of whether or not this is ACTUALLY an ALS or BLS call, if the basic provider isn't comfortable, who is the medic to think that he can force the basic into tech-ing the call? That is the biggest issue that I see here.

I don't care if it's a stubbed toe, if the basic isn't comfortable, then the medic gets the call. That is part of the responsibility that comes with that big capital P after your EMT-.

So...let's say that on a call (not the one originally posted) the paramedic does their assessment , determines the patient doesn't require their level of care and gives the patient to the EMT. The EMT comes back with "I'm not comfortable with that." In essence "I'm not comfortable and capable of doing my job." Part of the responsibility that comes with those big capital E M T letters after your name is acting as one.

Granted, this does to some extent need to go on a case by case basis, taking into account the experience level of the EMT and what is wrong with the patient, and there may be times when it would be better from the paramedic to continue care until they can explain things to the EMT. Or it may be more appropriate to be firm and force them to...you know...do their job.

If all the EMT is going to do is act as a driver then I would much prefer they are completely removed from any aspect of medicine, and instead a professional driver is hired in their place.

 

[TheLocalMedic]

So...let's say that on a call (not the one originally posted) the paramedic does their assessment , determines the patient doesn't require their level of care and gives the patient to the EMT. The EMT comes back with "I'm not comfortable with that." In essence "I'm not comfortable and capable of doing my job." Part of the responsibility that comes with those big capital E M T letters after your name is acting as one.

Granted, this does to some extent need to go on a case by case basis, taking into account the experience level of the EMT and what is wrong with the patient, and there may be times when it would be better from the paramedic to continue care until they can explain things to the EMT. Or it may be more appropriate to be firm and force them to...you know...do their job.

If all the EMT is going to do is act as a driver then I would much prefer they are completely removed from any aspect of medicine, and instead a professional driver is hired in their place.

Pretty strong sentiments.

While there certainly are those EMTs out there who are reluctant to tech calls, whether because they are weak in their skills/knowledge or simply lazy, most that I work with are willing enough to jump in if the call is BLS.

So if they're one of the lazy ones, and you'll generally know which ones they are, then yeah, go ahead and tell them in no uncertain terms to step up to the plate. If they're refusing because they lack a skill or knowledge base, then make a note of it and report it to a superior. A single incident may not add up to much, but if they're a repeat offender they'll wind up either doing remedial training or get a write up.

But there are certainly gray-area calls that, although I may be convinced are BLS, may make my partner a little wary of handling. People, especially EMS people, are often inclined to think of all the things that can go wrong in a given situation and EMTs may be less inclined to deem a given patient as BLS than a medic might (if you work in an area with BLS ambulances this is evidenced by all the instances when they call for an ALS rendezvous that turns out to be a whole lot of nothing).

So I will generally cut my partner slack if they say they aren't comfortable taking a call I'm trying to give them.

And sometimes they're right...

 

[ZombieEMT]

I do not work in a similar set-up but my opinion is that an EMT should not be able to just say, "I don't feel comfortable," unless they have a good reason to justify it. If you are not comfortable with treating patients, then get out of the field. If no ALS intervention/assessment, then BLS all the way. If it is a skill problem, then write it up. Address the issue. It is not fair to the medic on the truck to have to treat and report on all patient's because their partner does not feel "comfortable."

Let me ask you this, who does the medic go to when they "don't feel comfortable?" That patient needs to get to the hospital. Some patients are so severe medic assessment/intervention does not really do anything, what they need are doctors. That doesn't mean they call a doc to come out in the field to treat the patient.

 

[triemal04]

Pretty strong sentiments.

While there certainly are those EMTs out there who are reluctant to tech calls, whether because they are weak in their skills/knowledge or simply lazy, most that I work with are willing enough to jump in if the call is BLS.

So if they're one of the lazy ones, and you'll generally know which ones they are, then yeah, go ahead and tell them in no uncertain terms to step up to the plate. If they're refusing because they lack a skill or knowledge base, then make a note of it and report it to a superior. A single incident may not add up to much, but if they're a repeat offender they'll wind up either doing remedial training or get a write up.

But there are certainly gray-area calls that, although I may be convinced are BLS, may make my partner a little wary of handling. People, especially EMS people, are often inclined to think of all the things that can go wrong in a given situation and EMTs may be less inclined to deem a given patient as BLS than a medic might (if you work in an area with BLS ambulances this is evidenced by all the instances when they call for an ALS rendezvous that turns out to be a whole lot of nothing).

So I will generally cut my partner slack if they say they aren't comfortable taking a call I'm trying to give them.

And sometimes they're right...

So...basically you take it on a case by case basis, depending on the particular EMT and what is wrong with the patient.

 

[lightsandsirens5]

So...let's say that on a call (not the one originally posted) the paramedic does their assessment , determines the patient doesn't require their level of care and gives the patient to the EMT. The EMT comes back with "I'm not comfortable with that." In essence "I'm not comfortable and capable of doing my job." Part of the responsibility that comes with those big capital E M T letters after your name is acting as one.

Granted, this does to some extent need to go on a case by case basis, taking into account the experience level of the EMT and what is wrong with the patient, and there may be times when it would be better from the paramedic to continue care until they can explain things to the EMT. Or it may be more appropriate to be firm and force them to...you know...do their job.

If all the EMT is going to do is act as a driver then I would much prefer they are completely removed from any aspect of medicine, and instead a professional driver is hired in their place.

Ok, well I may have a warped perspective. I was basing it off of what I thought the rest of EMS might do.

I work for a service where the basic is never allowed to run calls. Like NEVER. Like the kiss your job goodbye and get reported to the state for abandonment kind of never. So, I don't really have a clue how the rest of the ALS world runs their Medic/Basic trucks.

 

[mycrofft]

So...let's say that on a call (not the one originally posted) the paramedic does their assessment , determines the patient doesn't require their level of care and gives the patient to the EMT. The EMT comes back with "I'm not comfortable with that." In essence "I'm not comfortable and capable of doing my job." Part of the responsibility that comes with those big capital E M T letters after your name is acting as one.

Granted, this does to some extent need to go on a case by case basis, taking into account the experience level of the EMT and what is wrong with the patient, and there may be times when it would be better from the paramedic to continue care until they can explain things to the EMT. Or it may be more appropriate to be firm and force them to...you know...do their job.

If all the EMT is going to do is act as a driver then I would much prefer they are completely removed from any aspect of medicine, and instead a professional driver is hired in their place.

1. If you aren't approaching every case on a case by case basis, you need to have your reset button pushed.

2. As a nurse, if a MD "assigns" or "delegates" me a job I'/m not feeling up to, I damned well better say no. If the MD gets pissy about it, then I don't need or want to work with him or her, and I'm going to be writing a report as I pack my locker up. (And if I have a union, then a rep or a lawyer will be there to make it a contest as to who has to leave).

Looking at a situation where one tech is delegating to another, MDs and lawyers are going to look at one another and grin. Like two airmen trying to pull rank on each other by the date they went into basic training.

But if your co-worker is a slug, by all means write 'em up and maybe refuse to work with them.

 

[DrParasite]

I was still not comfortable BLS'ing this pt especially with the extended txp we would be having to the other facility... so when asked by my partner i said honestly I'm not really comfortable BLS'ing this. He got mad at me and said i didn't want to do calls. and jumped in the back and BLS'd it himself. Was I wrong for not wanting to/ feeling comfortable BLS'ing this pt?

Can you define BLSed the patient? did you just walk him to the cot, and your partner did the state of life until you got to the hospital (maybe after throwing him on a NRB for fun)?

or did your partner perform a 12 lead, check a bgl, check his vital signs, perform a full assessment, and after determining there were no imminent life threats that he could fix, say "here you go, he's all yours."

the guy sounds FOS (as you so eloquently stated), but druggies do get sick, esp when you learn what drugs have done to their system over years of abuse.

what if he was having "the big one" because he just snorted cocaine and his heart was pumping around 240bpm? or he just mainlined heroin and now is barely conscious?

Let me put it this way: assuming he was legitimately sick, and this was discovered in the hospital, who called your boss, would you have been able to defend your actions? "Mr. Paramedic, why did you not do a 12 lead on the person who was clammy and having chest pains?" how about in a court room, or to the department of health? could you explain it?

triemal04 is right, part of being an EMT is being able to handle EMT calls. And there have been very few calls (I can think of maybe half a dozen over the past 14 years) where a medic said "he's all yours" and I said "are you sure????"

Based on your scenario, I would say an ALS assessment is warranted, but if there are no pertinent findings, no ALS interventions are needed, and BLS him all the way to the hospital.

 

[triemal04]

2. As a nurse, if a MD "assigns" or "delegates" me a job I'/m not feeling up to, I damned well better say no. If the MD gets pissy about it, then I don't need or want to work with him or her, and I'm going to be writing a report as I pack my locker up. (And if I have a union, then a rep or a lawyer will be there to make it a contest as to who has to leave).

Personal feelings only matter if the person giving direction agrees. Otherwise, if it is within your job description, within your scope, and something that a person at that level should be able to handle...you do it. Or you refuse, and deal with any fallout.

 

[Brandon O]

Personal feelings only matter if the person giving direction agrees. Otherwise, if it is within your job description, within your scope, and something that a person at that level should be able to handle...you do it. Or you refuse, and deal with any fallout.

One consideration, though, is that the person delegating to you may not know your experience and qualifications. The fact that a medic might feel he can manage a patient with BLS methods doesn't necessarily mean the green EMT he's turfing to feels the same.

You can argue whether that EMT "ought" to have that competence, or you can hash it out afterwards and convince someone they were wrong, but when you're on scene with a real patient, I think caution wins. If the patient comes unwound, it will be hard to argue later it was a legitimate down-triage.

 

[jrm818]

Personal feelings only matter if the person giving direction agrees. Otherwise, if it is within your job description, within your scope, and something that a person at that level should be able to handle...you do it. Or you refuse, and deal with any fallout.

Is the paramedic in this call "in charge" or not? If they are in charge enough to "give directions" with fallout, that's OK but should' they also write up the PCR and take responsibility for all decisions relating to the patient?

Same goes for "triaging" to BLS after an ALS assessment. This doesn't seem much different than the dynamics when a BLS ambulance asks for an ALS intercept....if a medic evaluated the patient and determined they were not needed, I would expect that medic to document their assessment....the BLS provider certianly can't be expected to do that.

anyone want to take bets on whether the OP's partner was going to write up his own trip sheet?

Let's remember that this was a sweaty patient with "severe" chest pain, some sort of oxygenation deficit, and a complicated history. Sounds like demanding an ALS assessment is well within the realm of "appropriate" care.

As to skills of the OP/any BLS provider...I don't think the issue is so much "not knowing what to do." Frankly a patient like this is pretty easy on the skills. If no ALS is available, BLS treatment consists of +/-O2, ASA, and CPR if the patient croaks. I suspect the "discomfort" comes from knowing that more can potentially be done for the patient than waiting to see if they arrest in the next few minutes, and that such higher level care is easily and immediately available.

 

[jrm818]

triemal04 is right, part of being an EMT is being able to handle EMT calls. And there have been very few calls (I can think of maybe half a dozen over the past 14 years) where a medic said "he's all yours" and I said "are you sure????"

Based on your scenario, I would say an ALS assessment is warranted, but if there are no pertinent findings, no ALS interventions are needed, and BLS him all the way to the hospital.

Not to be overly combative, but in support of the OP...

ALS assessments overlap with basic assessments -- the patient doesn't change. A sweaty patient with a strange history complaining of chest pain that is "severe" counts as a "pertinent finding." Even if the 12 lead is normal, it would seem a stretch to call this patient low risk. What possible reason is there for leaving the BLS partner to ride this in? ALS provider too tired? Just don't care enough? I don't know, but I'm pretty sure the answer is not c) there is no chance this patient will deteriorate and require advanced care en route.

 

[Bullets]

Almost nobody without underlying pathology can drop their oxygen saturation by voluntarily holding their breath.

When we do training with our cadets I do this all the time. I can really drop to 90 before I have to breathe. I've seen many of our providers do it....

Also this was an ALS call

 

[Brandon O]

When we do training with our cadets I do this all the time. I can really drop to 90 before I have to breathe. I've seen many of our providers do it....

Also this was an ALS call

Are you a smoker? That's a nice chunk of CO2 to tolerate. (Supposedly hyperventilating helps, though.)

 

[Bullets]

Are you a smoker? That's a nice chunk of CO2 to tolerate. (Supposedly hyperventilating helps, though.)

nope, perfectly healthy 25 year old, maybe because i am an active SCUBA diver?

 

[Brandon O]

nope, perfectly healthy 25 year old, maybe because i am an active SCUBA diver?

Not sure... interesting though. Maybe someone else here has more background with dive medicine. (Good topic for a study maybe...)

 

[Bullets]

Not sure... interesting though. Maybe someone else here has more background with dive medicine. (Good topic for a study maybe...)

I think its more an issue with the RAD-57 we use, while a decent piece of equipment, its far from perfect. If its not placed perfectly on the finger it will throw weird numbers.

 

[triemal04]

One consideration, though, is that the person delegating to you may not know your experience and qualifications. The fact that a medic might feel he can manage a patient with BLS methods doesn't necessarily mean the green EMT he's turfing to feels the same.

You can argue whether that EMT "ought" to have that competence, or you can hash it out afterwards and convince someone they were wrong, but when you're on scene with a real patient, I think caution wins. If the patient comes unwound, it will be hard to argue later it was a legitimate down-triage.

I'm going to repeat myself; this would fall under "on a case by case basis." Again, there may be times where the EMT will legitamitely be uncomfortable, and for justifiable reasons and it would be appropriate for the paramedic to retain control. But...that only works to a point. If an EMT is not willing or capable of learning or becoming comfortable with actual patient care and working within their scope...well...maybe time for a new job.