When IFT=lower level of care/abandonment

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GloriousGabe

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I've always felt very odd about taking a PT from one facility to another where they have treated the PT with things I can't do in the ambulance. What happens when those things wear off? I'm pretty sure it's not legal, either. You can't t/f to a lower level of care. BLS is definitely a lower level of care from the ER. For ALS this isn't as much of a big problem as it is for BLS.
 

DesertMedic66

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During transfers the patient is still technically under the care of the sending Doctor.
 
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GloriousGabe

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During transfers the patient is still technically under the care of the sending Doctor.

How can the Dr tak care of that PT? If they dosed the patient with something and it wears off during transport how am I supposed to redose them? I'm only an EMT-B.
 

NomadicMedic

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Unless there is an actual intervention in progress, you should be fine.

Patients receive treatment and are medicated all the time before being transported by a BLS unit. And if something happens, perform BLS and go to the hospital.
 

DesertMedic66

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How can the Dr tak care of that PT? If they dosed the patient with something and it wears off during transport how am I supposed to redose them? I'm only an EMT-B.
What kinds of medications is the hospital staff going to be giving that is going to wear off during transport for your BLS patients?

If you don't feel comfortable taking a patient from point A to point B with BLS resources then talk to the doctor and your supervisor.

Our BLS units are 90% IFTs. Never once in the 2 years I was on BLS did I run into the issue of transporting a patient where something "wore off" during transport. If your patient has been having pain find out when the last time they were given pain meds was. Our hospitals are very good about giving pain meds 10 minutes before we load up. If the patient is going to need more pain meds in route then you should probably not take that patient at the BLS level without a nurse or doctor rider.
 
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GloriousGabe

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It's never a discussion as to who we bring where. It's "take this PT to the truama center 90 miles away, now".

Had a seizure PT. Meds wore off. Seizing in ambualnce. What am I supposed to do?
 

Akulahawk

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The sending and receiving physicians confer and determine an appropriate level of care necessary for transport. I send patients out all the time (BLS even!) that are still receiving antibiotics or some other drip when the transport arrives. How do I keep them from exceeding their scope of practice? I don't let them take over care from me until the medication has completed. Sometimes the patient gets motion sick, so sometimes we'll give Zofran or something similar to the patient before transport to help prevent problems during transport. Here's how I prevent the crew from exceeding their scope of practice: I administer the medication, sign it off, advise the crew what I've done and what to expect (if necessary). Once I turn the patient over to the crew, I do NOT intervene after that unless it's absolutely necessary as it's their patient now.

Something I do is "allow" the crew to take over care to provide better care than I can at that particular time. I know what protocols the crews function under and sometimes I'll advise them that they may want to follow their protocols for providing care... because sometimes it may take me longer to obtain an order for something and administer it than it would for the crew to do the same thing.

As an IFT provider, you also have the responsibility to recognize when the patient requires care beyond your ability to provide. While a patient may be intended to be sent out BLS, if the patient is unstable, it's your job to recognize that and refuse to do the transport at that level. I have refused transports because the patient wasn't stable for BLS (or even ALS) transport. I have told sending facilities that the patient needs further stabilization before I could accept the patient. Those few times I have done this, the patient really did need additional care and I was glad to accept the patient later when the patient had been stabilized sufficient for transport... and the facility usually thanked me for my attentiveness as it prevented them from getting into trouble for sending out a patient inappropriately.
 

DesertMedic66

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It's never a discussion as to who we bring where. It's "take this PT to the truama center 90 miles away, now".

Had a seizure PT. Meds wore off. Seizing in ambualnce. What am I supposed to do?
Treat the patient as a BLS provider and made a decision on what is going to be best for the patient (contact an ALS unit, divert to the closest hospital, or continue transport to the original destination).
 

Akulahawk

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It's never a discussion as to who we bring where. It's "take this PT to the truama center 90 miles away, now".

Had a seizure PT. Meds wore off. Seizing in ambualnce. What am I supposed to do?
If you're BLS and you need to take a trauma patient 90 miles to a trauma center, and the patient is likely to need ALS intervention during transport, you need to bring that up. If you have a seizing patient, you don't have to do much... you keep the patient safe, apply oxygen as necessary, provide ventilatory support PRN, and transport to the closest, most appropriate facility. What would you do with that same patient in the 911 arena? Most of the time you don't have to do much beyond that. You need to think about your options... and that may include calling for ALS.
 

Chimpie

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Had a seizure PT. Meds wore off. Seizing in ambualnce. What am I supposed to do?
What would you normally do if you had a patient in your ambulance and they start seizing?

The protocol is the same.
 

ERDoc

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A large portion of the burden falls on the sending doc. They are responsible for making sure they are requesting the proper level of care for the transfer. Any trauma pt should be going ALS unless it is isolated ortho trauma. I think more info is needed from the OP but something doesn't sound right about the transfer. Anyone remember that bad premie case in Florida a few years ago?

http://ems-law.net/2011/05/20/10-million-verdict-in-florida/
 
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GloriousGabe

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It just doesn't make sense. In order for that "higher level of care" to happen those folks need to be present. Sending a PT in my BLS bus is definitely a lower level of care and definitely abandonment. If the PT were to code and die I bet a lawyer would have a field day. I've already been sued three times. I don't need a fourth!!!!
 

Jim37F

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As the attending EMT the onus is on you to say "I don't feel comfortable taking this patient, I don't believe they are stable enough for BLS transport" and then call for ALS. However, I believe you had said in a previous thread that you only have one medic unit available for a 3 county area or something like that? So if ALS simply is not available, and the patient NEEDS the higher level of care (say your trauma patient needs the surgeons at the trauma center) then what? Just let the patient die in the ER simply because?
 

MonkeyArrow

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It just doesn't make sense. In order for that "higher level of care" to happen those folks need to be present. Sending a PT in my BLS bus is definitely a lower level of care and definitely abandonment. If the PT were to code and die I bet a lawyer would have a field day. I've already been sued three times. I don't need a fourth!!!!
Sometimes, you have to stop worrying about being sued. You've already mentioned that you've been sued multiple times in multiple threads. To a point, we already practice defensive medicine but if you have that thought constantly hanging in the back of your mind about getting sued, you won't be able to perform properly. Anecdotally, I work with an ER doc who has been sued and overorders a lot of unneeded tests and labs (he has built quite the reputation of ordering everything under the sun) and just practices medicine unlike any other doc presumably because he's scared of getting sued again. Now whether you are doing something wrong that you are getting sued as a BLS provider three times is a different discussion.
 

DesertMedic66

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The patient needs to be stable enough to be transported by whatever means the doctor feels is the best.

If you don't feel comfortable taking a transport then don't. If something is out of your scope of practice then don't do it.

As for being sued 3 times: http://www.hpso.com
 

squirrel15

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I don't understand what in the world you're doing that you have been sued three times as a basic, but I digress. In order to transport mostly the patient will be handed over to a lower level of care, even ALS is a lower level of care. Its your responsibility to make sure the patient has been given appropriate meds before leaving. If a patient was given pain meds and those magically wear off, I'm sorry the patient may be in some pain during the rest of the transport, but the receiving meds should be able to fix that when we get there.

BLS IFT is pretty simple, and the patients are most likely stable. If you feel a patient isn't stable, talk to the doc and your supervisor and refuse the transport. That easy.
 

Akulahawk

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It just doesn't make sense. In order for that "higher level of care" to happen those folks need to be present. Sending a PT in my BLS bus is definitely a lower level of care and definitely abandonment. If the PT were to code and die I bet a lawyer would have a field day. I've already been sued three times. I don't need a fourth!!!!
You probably need to have someone sit down with you and truly school you about things like "abandonment" and "negligence" and "competence." You do not seem to understand these things as it pertains to EMS, and medicine in general. What you also need to understand is that sometimes a patient that's very sick only truly needs BLS for transport but also needs the surgeon waiting for them on the other end. As I've said earlier, if you're not comfortable taking a patient because you believe and can clearly articulate why a patient requires care beyond your ability, it's incumbent upon YOU to speak up and say so. Worst case scenario is the sending facility must send someone that's qualified to provide the level of care necessary. However, the onus is primarily on the sending facility to determine the appropriate level of care necessary during transport. They may not exactly know your limitations, but they know that if a patient doesn't need a monitor or doesn't need anything other than a basic IV fluid running during transport, BLS is appropriate. ALS can do many things... but the choice of CCT-RN is necessary if the patient requires ICU level care during transport. They know those basics... and if YOU know those differences, YOU can help them choose the most appropriate transport resource and it may NOT be your company.
 

ERDoc

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I think this is where EMS education is lacking. The problem is that a lot of BLS people don't know when they are getting in over their heads. They don't know what they don't know. If I am the sending physician, I am responsible for deciding what level of care is needed, if that level cannot be found then it falls on me to manage that pt until the appropriate level of care can be found. If something goes wrong, I am going to be on the hook. Why do you think the doctors in that Florida case settled? They knew they were hosed. Luckily for me, every ambulance around here has medics and many have CCT medics when needed.
 

RedAirplane

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As I was taught, you can't go down, you can only go up. Otherwise it's abandonment.

EMT can accept patient from EMR or EMT
Paramedic can accept from EMR, EMT, or Paramedic
Doctor can accept anyone because they're the "highest"

There are several flaws in this (does nobody ever get discharged? Do all transfers need MDs?) but this is the very simple way things are explained in an EMR or EMT class.
 

DesertMedic66

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As I was taught, you can't go down, you can only go up. Otherwise it's abandonment.

EMT can accept patient from EMR or EMT
Paramedic can accept from EMR, EMT, or Paramedic
Doctor can accept anyone because they're the "highest"

There are several flaws in this (does nobody ever get discharged? Do all transfers need MDs?) but this is the very simple way things are explained in an EMR or EMT class.
That's going to be system dependent. There are a number of systems where paramedics will hand over care to an AEMT or EMT. I believe Los Angeles does this (fire medics and private BLS company responds to all 911 calls, the medic assess the patient and then deems the patient needs ALS or BLS).
 
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