Opinions: Medic Refuses Intercept

[brentoli]

Problems I see:

1. There is no automatic dispatch of ALS
   
2. There is no radio dispatch of ALS (Cell phone calls normally are not recorded)
   
3. Your medic has to respond with his personal vehicle, does that include personal equipment
   
4. We only have one side of the story, and the story is slanted towards bad medic in its writing
   

Those first three points need fixed, immediately. If they can not be fixed, scrap your ALS service and contract with professionals. Your system is putting everyone at liability that is not necessary. Your dispatchers are liable for not sending the right equipment, your EMTs are liable for not having radio proof of call progression, your medics are liable for responding with a personal vehicle.

All of the above put your public you are there to serve in a bigger danger when they call 911.

RANT

As far as number 4 goes, I hate reading stories like this on any forum. You will always only see one side of the story, and there is no exoneration for the other party. Even assuming that what the OP said is true, with no embelishments, and he left out all of the side stories not needed to make a judgement in this case, we still wouldn't have both sides. People always come to the forums with a bone to pick though. We hear about how bad this was how bad that was, things are exaggerated, embellished, and spun.

I am all for learning with case studies, and investigation into situations. I wish people would take the time to write out a calm, well communicated, neutral post before they tried to get the public influence. Save the spin for congress.

/RANT

[Richard B the EMT]

Obviously, I wasn't on the call in question, but I now add comments based either on NY State DoH, or FDNY EMS Command protocols, and personal opinion/experiences.

As one who has worked both the field and the EMD, as has been pointed out on numerous threads, callers to 9-1-1 sometimes lie to get an ambulance there sooner. The flip side of the coin is, the caller may not have a clue to what the situation is, and from inadequate information given to the EMD, in dual level systems like the FDNY EMS, a BLS is sent, solo, and on arrival, realizes that ALS is needed, and then requested. However, the ALS is already a duo of Paramedics, and already in their ambulance, so they will respond.

This may not match the situation of the OP.

A protocol I am used to operating under is, even while doing BLS patient care, if the ALS is further away, time-wise, than either awaiting ALS arrival, or meeting up in an intercept while on the way to a hospital, ALS is canceled off the assignment by the BLS, and the BLS continues treatment while doing the diesel drip therapy (please note that nowhere in FDNY or NYS DoH literature does it ever mention such in that style wording) to the hospital.

If someone is on call to respond from either beeper or telephone notification of an assignment, then they are to respond, with no difference held as to volunteer or paid. This kind of coverage is usually prescheduled, so childcare should have already been arranged, even if it is on less than 24 hours notice. No childcare? Let a scheduling officer (under whatever name the local agency's position carries) know that the individual is going to be unavailable, why they are going to be unavailable, and make arrangements for someone else to cover.

If we are talking of a person being on paid standby to respond, they have the full duty to act (respond). If in that status, the individual refuses an assignment, I see it as malfeasance, unless there is a damned good reason why they are unable to respond.

Note that I say unable, due to circumstance or condition.

I use the following to illustrate one type "condition".

In an Inter-facility transfer service I used to work for (now bought out at least twice following my leaving), on "night call" (pager or telephone notification of assignments, and paid by the assignment), the ambulances went home with the EMTs, the "ambulette" wheelchair coaches with usually non EMT drivers. A call came in, they'd meet up, the ambulette driver would take over the wheel after locking up the "'lette'", and do the call, later drop the driver back to the lette.

I was working an ambulette one night, and was paged to locate another ambulette that had gone "missing". Unfortunately, I found the driver.

A block from his house, where I had picked him up to go to the base when neither of us was on the night call, I took a chance that he was in the local tavern. He was there.

Drunk.

After advising the dispatcher, I was told the drunk personnel was not being paged for the remainder of the overnight, and I ended up being given his calls, making some profit for myself.

The drunk was suspended for 2 weeks without pay, after the assistant manager was driven by the general manager to the ambulette to bring it, and the pager, back to the base. The man was lucky he still had a job.

[FredG]

Based on my experience and knowledge from the other end of NYS, working in a rural volunteer service with paid ALS fly cars provided by 2 different entities (depending on location), I agree with most of what richard posted.

My biggest gripe with the description of this call is that ALS was not automatically dispatched. In my county, dispatch uses EMD to prioritize all calls on a scale of A-E. Higher letter is worse condition. The general dispatch recommendations are : A&B are BLS only responses (A non L&S, B is L&S), C-E are BLS/ALS dual response (C - BLS L&S ALS non-L&S, D-E are both L&S). I feel that this is a good response matrix for a rural area, simply because of the distances involved. I would rather see ALS started and cancelled rather than not be available at all.

Under this system, Chest Pain calls are classified as either C or D, depending on age and respiratory effort. So, regardless of the situation, an ALS unit is dispatched immediately. In a rural area, this is the smart thing to do. In NYC (where I used to work, years ago), the need for dual dispatch is a bit less because the hospitals are closer to each other.

As for diesel therapy, I would absolutely use it for any unstable patient where ALS was effectively unavailable or further out than the transport time to the ED. In my area, the nearest ED is about 15 minutes away and there is an ALS flycar stationed in the same town as the hospital. But, that unit is only 16 hours. From 2300 to 0700, our nearest ALS unit is coming from a town 22 miles away in the other direction.

My next issue with the OPs description is that the ALS tech uses his personal vehicle to respond. Being a paid ALS provider with a duty to respond should require that the ALS tech be given a marked response vehicle fully equipped in order to respond....and that ALS tech should be dispatched via radio or pager by the dispatch center, not telephone from the BLS crew. In this case, what does the ALS tech do when called for Mutual Aid? Fly around in a personal vehicle? If the vehicle is carrying department equipment, is it properly insured?

However, cell phones do have their uses with ALS intercepts, I have on occasion called the ALS unit responding to a call to give them a heads up on the patient status so they can modify their response as appropriate, usually to slow their response for a stable patient (our regional medical council does not allow BLS to cancel ALS responses, but we can confer with ALS and they can self-cancel).

As for the duty to respond...it shouldn't matter whether the person is paid, paid on-call, or volunteer. If they signed up for a shift, they have a duty to respond. The view at the state level may be different, but that's my agency's policy. My dept is all volunteer and we have suspended members for not responding on their call night. If they can't cover their shift, all we ask is that they notify their partner, notify an officer, and try to find a replacement.

[croaker260]

Now I agree that the medic was in the wrong, so I am not defending him.

That said... I feel I should offer you a bit of friendly advice.

I dont know if It has been specifically discussed, but discussing such detailed specifics of an ongoing diciplinary process in a public forum, especially when you are involved in the disciplinary process (and presumably some kind of leadership position- appointed or implied) , would be grounds for termination in my service I am sure. I know that your a volunteer with a volunteer service, but at the end of the day, your best bet is to approach each leadership conundrum as if you were a paid employee whose reputation and career depended on you getting it right the first time. EMS is a very small world.

Just food for thought, respectfully submitted.

Thank You.

Steve

[maine_emt]

Yes according to the OP the ALS provider failed his duty to act, but it seems there is a systematic problem as well. Not automatically dispatching a paramedic to a chest pain call in concerning as it is, let alone later dispatching them with a cell phone.

I think the service's policies should be looked at as well as disciplinary actions for the medic.

[medic15401]

If leaving his kids alone is an issue then maybe he should have been more responsible and NOT taken the "duty" for the shift. I also believe that there is some negligent behavior on behalf of this medic for NOT performing his job in this case (based on the info given that is). My question is that we are asking the same type of questions about the distance and time to the hospital, but I am wondering this:

Was the FD ALS intercept made en route, or did this BLS crew sit and wait? Maybe I missed the answer to that question somewhere, but if the crew sat on the scene waiting for the FD to arrive, then isn't there a problem with that? How many times on this site do we get "basics" justifying their worth, but in this case where they recognized an urgent situation, they sat! Why? Does the distance really matter? There are basic trucks/ units/ buses (region specific, pick one) who run 911 calls all the time and "handle" CP calls by realizing and transporting based on their findings.

My point is who cares that this "medic" (and I use the term loosely) refused to respond. I'd like to know why a crew of professionals where on the scene, and didn't just handle the pt once they found out that ALS care was unavailable. As a medic I don't make it my practice to transfer MY CP pts to basic level care, but why take the time to wait (if that was the case). Unless this FD was en route, and could meet them road-side I say they should have just transported.

New member chiming in.

I am an NREMT-P registered with the national registry and licenesed in the state of Arkansas to provide Emergency Medical Care.

I have a problem with the statement made by this poster. First off we are all Basics. First and foremost we are EMT's some of us just have a few extra letters behind our name. I find it hard to believe that you never made a mistake in your career. Don't knock the basics because you have the god syndrome and think you are better than them. If it weren't for emt's there would be no medics it is just a stepping stone you know.

[Dustdevil]

^ Bad start.

[HERBIE1]

New member chiming in.

I am an NREMT-P registered with the national registry and licenesed in the state of Arkansas to provide Emergency Medical Care.

I have a problem with the statement made by this poster. First off we are all Basics. First and foremost we are EMT's some of us just have a few extra letters behind our name. I find it hard to believe that you never made a mistake in your career. Don't knock the basics because you have the god syndrome and think you are better than them. If it weren't for emt's there would be no medics it is just a stepping stone you know.

A "mistake" is accidentally giving 3mg of Morphine instead of 2. A "mistake" is documenting incorrect vital signs.

Refusing to respond to a call is NOT a mistake, it's a dereliction of duty and goes against everything we are supposed to be about. That person should never be allowed to provide EMS again, IMHO.

This situation was not about the provider's level of training. If an ALS intercept was not an option, then the EMTB's would have had no choice other than "diesel therapy".

If I were the family member of that patient and found out that someone refused to come to the aid of my relative, my first goal would be to have that person's license revoked. Barring that, I promise that I would do everything in my power to make sure that provider would be punished to the fullest extent allowable by the system policies.

[RomeViking09]

<!--quoteo(post=221936:date=Aug 21 2009, 09:50 PM:name=JakeEMTP)--><div class='quotetop'>QUOTE (JakeEMTP @ Aug 21 2009, 09:50 PM) <a href="index.php?act=findpost&pid=221936"><{POST_SNAPBACK}></a></div><div class='quotemain'><!--quotec-->I can't help thinking though, w/o trying to highjack the thread,

Sorry, just thinking out loud.<!--QuoteEnd--></div><!--QuoteEEnd-->

Since we are hijacking without intention.....

Does anyone else think 4mg MS is a little high for a loading dose on a known inferior?

I am kinda sheepish with my drugs at this point.... so maybe it isn't.

I'da started at 2.5.

2-4 mg IF THE BP WILL SUPPORT IT is the "recommended" dose of morphine for any MI. For an inferior you would want to get the BP up first, give the NTG and ASA, and then Morphine (if the BP is still above 90 to 110 depending on your protocol) The patient needs to reduce the oxygen demand on the heart and morphine will do that.

[medic82942003]

I am old school,give 2mg + 2mg, the old 2+2 method. For MS.

Edited September 8, 2009 by medic82942003