Sanity Check Needed

[neoboi]

Ok....so I need a sanity check..for a call

Dispatch:

BLSGS265 respond to urgent care code 2 (no lights or sirens) for a 33/f c/o abd pain. Pt --> ER for further dx/tx.

On scene at urgent care: 33/f c/o 7/10 peri-umbilical pain and dizzyness. pt just recieved 25 of demerol, 12.5 of phenegran.

on exam, Pulse 152, BP 116/84 R 24. no rebound or guarding, no provoking factors, dull throbbing pain, peri-umbilicial pain. no other findings. pt denies Past Hx.

we stat paged the urgent care doc overhead to the pt bedside, they ran a strip, showed Sinus Tach at 154. SaO2 92% on RA.

Doc said, she should be fine for xfer.

pt begins to c/o "sinking feeling" begins to shivver and complains of "anesthesia" feeling.

what we did: 6Lpm O2, shock position, MD opened NS IV to wide open, and we transported 2 miles to ER code 3. (no traffic on streets).

so, we get to ER they room her, and dispatch calls us back to quarters.......

county med control wanted to know why we decided to go code 3 right off the bat...

our explination: ALS response is 7-10 minutes. our trip at code was 3 minutes......sure a paramedic has drugs...but, they're farther out than the ER doctor is.....

county med control accepted this, but frowned at the code 3 decision right off the bat citing that if we think we need code right off the bat we should call ALS.

i can see their point, but time vs. distance was on our side. input on this??

also: we told the doc of our plan for code 3 and she endorsed it....

was i wrong?

:shock: <---me eager for learning!

[xselerate]

The pulse itself would be enough, in my humble opinion, for me to light it up. With the associated mental status changes your patient was describing I wouldn't have had to think twice. And something you hear me ask quite frequently.... central eta on the medics? 10-4, you can cancel them, were closer to the er.

done.... if i can't get medics there by the time im ready to go and i have less then a 5 minute trip to an er im moving.

Although I'll admit I would never ever be questioned for going straight to an er and using my own discression with lights/sirens.

[pyroknight]

Even as an ALS provider, I am not sure I would go code 3 with this patient. She's 33, I have no reason to believe that she's exsanquinating, she's received pain medications - so I'm not OVERLY concerned. I can see where a BLS provider might be a little nervous, so I would certainly not FAULT you for going code 3 (I just happen to believe that it often puts everyone at greater risk with little reduction in transport time). Any supervisor worth their salt should have your back as well. Second-guessing providers when you weren't on a call should be avoided unless glaring errors are committed (which, in this case, was obviously NOT the case).

[Dustdevil]

If the transport was that short to begin with, then ALS or BLS, I wouldn't choose to go code 3. What's it going to save you? A grand total of 30 seconds maybe? Sorry, I'm not putting my partner and patient at risk for that. But I agree with Pyro, I can certainly understand how a basic would be uncomfortable with the situation and anxious to get it over with, the sooner the better. Therefore, as a supervisor, I would not be terribly upset by the decision.

Of course, I'm not really clear on exactly what their concern was with your handling of the run. Was it because you chose to run hot? Was it because you chose to take the patient and not turn it over to an ALS unit? Was it both?

In a perfect world, you would have turned it over to ALS because of the ALS interventions already established. Just like a medic should not be turning ALS patients over to EMT's, neither should nurses or doctors. For that matter, you shouldn't be accepting them. However, I also understand that many of them simply don't know the difference, and all ambulance drivers look the same to them. Trust me, they don't read your patch or have any idea what it means. And I tend to agree with you that, in this particular situation, simply snatching and running the 3 minutes was probably a viable -- and possibly even the best -- option for the patient, which is what counts. Although I damn sure wouldn't make a habit of that. Sooner or later, the patient is going to burn you.

If anybody needs their ass reamed over this, it's the dispatcher who FAILED to properly assess and dispatch this to an ALS unit. Somebody needs some serious remedial education. If they're not fired.

[pyroknight]

Other than being tachycardic and tachypneic, this patient appears stable. Depending on the information given to dispatch, they may not be at fault here either. I would be interested in knowing what was actually WRONG with this patient.

[PRPGfirerescuetech]

I think your looking for feedback on your decision not to call ALS due to distance.

There are multitudes of theories on this, my theory has always been if the MD is closer than ALS, then go to the ER. ALS should only be called when ALS can be used.

Looking at it from your administrations standpointe, they are likely thinking it from a general liability side, where you would assume less liability for dispatching ALS, and never getting them.

I wouldnt worry about it. Sounds like you did right, and actually thought outside of the box.

Good luck

[Ridryder 911]

I agree that I don't see the need for emergency traffic. The pulse rate is not that high (pain will elevate) and 33 of high risk of ?.. 2 miles with no traffic a whopping 3 or 4 minutes transport time if you drove nice and smooth (in which abdominal pain patients need), and like Dust describes you saved a 30 to 40 seconds.. that long to open the doors.

As far as ALS .. why ? Your 2 miles out.. what are they going to do in 3 minutes.. pain meds.. hmm ...nope, she already had analgesics and anti emetic. So why call for ALS?

Again, I believe we are seeing more and more people not knowing how to treat patients. ALS is great and should be used appropriately, but this was a simple hospital transfer from point A to point B.

R/R 911

[Guest]

The Doc and dispatch were definitly at fault here. You, as a BLS unit should have never been sent to this facility. Lights and sirens, i agree were a bit much concidering time and distance covered. As a medic i problably would not have done anything more if i were there than you did. Again a matter of time and distance. Although i think i would have asked more about her condition. Maybe you did, i don't know but you didn't share here if you did. I mean was she preg., in a fight, accident that wasn't reported, how long had she been like this before seeking help? those sorts of things.

Besides that i think you did fine, No worries.

Race

Edit: sorry i just reread, i see now where you listed the Hx. scratch that comment

[xselerate]

In a perfect world, you would have turned it over to ALS because of the ALS interventions already established. Just like a medic should not be turning ALS patients over to EMT's, neither should nurses or doctors. For that matter, you shouldn't be accepting them.

In NYS BLS can not take a patient who has any type of running IV, which you mentioned was wide open. We have to wait for ALS. We can take the patient if a saline or hep lock is in place but that's it. Is it the same for you in Conneticut neo? I'm just curious.

[neoboi]

So.....our dispatcher just takes the orders from the nurses and doctors for transfers and the nurse or doc at the sending facility is expected to know what kind of transport to the hospital the patient needs.

one other detail i forgot to point out was that had we not ran hot, we would have had a 12-15min transport time.....the best available path around the hospital we were going to has like 9 stop lights and 4 stop signs. (We were going to stanford university hospital ER). My greatest concern was her heart rate and her pulse in transport actually went down a little.....but, it still had me scared shitless that she was going to have some sort of tachyarrythmia.

in the end, nobody got in any trouble and what county med control got all upset about was that we *decided* to go hot, not that we did it.....they're pissed that we didnt call als cuz they think that private services are only good for transporting psych patients. they would have us rather transported her with no lights and sirens, and then about 1 min into the transport call in an upgrade, which sounds stupid to me....

on the IV thing.....we can transport anyone with plain NS, D5W or D5NS, D10W or D10NS or LR, provided there's no additives. Thats running into any type of indwelling catheter, and we can monitor the drip rate as perscribed by the doctors orders.