Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

New Service Rules

Here is another Normal Sinus Rhythm post. The topic this week is themeless. Read the rest of the NSR Blog posts at NSR Week 9.

You get a memo from the ALS coordinator (just below the medical director, the person responsible for oversight of the medics) .

We have had a problem with inappropriate triage of ALS patients to BLS care. As of yesterday, all calls dispatched as ALS will have the medic in the back attending to the patient.

Signed ALS Coordinator and medical director.

One of the problems in EMS (Emergency Medical Services), that is present in everything else, is misbehavior. One example of this is in systems that mix ALS (Advanced Life Support – medic, nurse, doctor with needles, tubes, drugs, . . . ) and BLS (Basic Life Support – stuff that really works, except for spinal immobilization) together. Either BLS on the ambulance and ALS responding in a fly car (or whatever terminology you use for a separate ALS response vehicle) or the ambulance crew is made up of a medic and a basic EMT.

One way that misbehavior exhibits itself is when there is a call that appears to be an ALS call, but the medic states it is a BLS call. He refuses to be the person taking care of the patient. We will assume, for the sake of argument, that everybody knows that this patient does have a legitimate ALS complaint. Let’s say chest pain, but the medic claims that the patient just has indigestion.

Never happened.

I’ve seen it happen with doctors, nurses, medics, and basic EMTs. Some people just jump to conclusions without assessing thoroughly, some have such a bias about what a real chest pain patient should look like, that they practically need to be hit over the head with a life threatening arrhythmia to be convinced that the epigastric discomfort is actually cardiac in origin. There is plenty of evidence of health care professionals doing this. Usually it is a doctor, who is documented as being the one to make this mistake, because his gut feeling was that the patient did not have a serious medical condition. One reason nurses and medics do not have so many documented cases is that they do not generally have the final say on treatment.

So the medic decides that the patient with chest pain does not have chest pain, but just indigestion. No ECG, no good history, no real physical exam. They patient just doesn’t look the way the medic expects a chest pain patient to look, at least, if the chest pain were of cardiac origin. Never mind that atypical cardiac presentations may be as common as typical presentations.

The EMT rides in the back. Or, if the medic responds separately, the EMTs agree to recall the medic, who has not notified dispatch that he is on scene, yet. This way the medic does not need to do any paperwork, other than a recall chart, since he never saw the patient. At least, that is what the documentation will show. So no record of patient contact means no liability for an incompetent workup. That is the way the medic will view this. The patient responded that he did eat a heavy meal before this pain began and that burping (eructation) relieves the discomfort, temporarily. That is enough to convince the paragod that this is not something worthy of his time. It isn’t the pale, cool, soaked with sweat (diaphoretic), crushing substernal chest pressure radiating down the left arm, can’t get the electrodes to stick to the patient, because benzoin is something that other people have to use. In other words, this presentation, that the medic thinks is typical, but is uncommon, is the only thing he is likely to do something about and feel that he isn’t wasting his valuable time. Got more important things to do. Hey, Springer is on.

Nothing about history of diabetes, previous MI (Myocardial Infarction or heart attack), angina, cardiac catheterization, any other history, medication, allergies, because Medic Magoo sees all.

When they get to the hospital, either the medic is not there (released/canceled by BLS) or the medic blames the EMT for not telling him what was going on. In other words, the EMT did not do his job for him. Even though the EMT really was doing his job – taking care of a patient with a legitimate cardiac complaint, because the medic did not want to do anything more than drive.

One medic/EMT system, where the ALS coordinator and the medical director claimed to have a problem with this, chose the wrong solution. There are other wrong solutions. Their solution to the problem?

On any call dispatched as ALS, the medic will provide all care. This will guarantee that the medic does not release care to his partner. It does nothing to get the medic to understand what he is missing in his assessment. It does not require that the medic be competent. It does nothing to differentiate between the medics who appropriately release patients to their partner.

The problem is only with some of the medics.

The solution is to force all of the medics to do things in this thoughtless way.

The problem is that some of the medics do not care or do not understand.

The solution is to ignore the opportunity to use this to remediate those who don’t understand. To ignore the opportunity to find out what the problem is in those who do not care.

There is no discrimination between competent and incompetent.

Ask EMS instructors what the most important ALS skill is. Many, maybe most, will tell you it is a good assessment. This ALS coordinator and medical director have decided that the most important ALS skill is following the direction of dispatch.

Dispatch made the call ALS, because hemorrhage is an ALS call. You arrive on scene and find that it is a paper cut. There is currently no bleeding. There are a couple of drops of blood on a paper towel used to control the hemorrhage.

Dispatch made the call ALS, because abdominal pain is an ALS call. You arrive and treat the patient as having abdominal pain – IV and fluids, per protocol – not performing a good assessment and realizing the patient has epigastic pain as a symptom of a heart attack.

The first case is just making more work for the paramedic. Not really a problem, unless all of the calls are ALS and the medic is spending all of his time treating patients and writing charts. There are places where this is typical.

The second case, just adds an IV to the treatment the patient received, and maybe they are on the heart monitor.

No aspirin. The most effective EMS drug for a heart attack.

No NTG (NiTroGlycerin).

No morphine or fentanyl. The medic would have to get permission to treat abdominal pain with opioids, because the protocols are written by a medical director who is afraid of surgeons and is not familiar with the research on pain management. But that is a different topic.

No 12 lead ECG. That would, in a smart system, lead to a cath lab activation if the medic interprets the 12 lead accurately. There is no good reason why the medic should not interpret the 12 lead accurately.

No beta blockers or other treatments that might be beneficial.

After all, this is just a whiny abdominal pain patient. Probably just ate too much. He should be put in one of the out of sight, out of mind beds.

This is dangerous. If there is a problem with some medics, the solution is to address the problem with those medics. Punishing everyone for the mistakes of a few is not good medicine. It may work in boot camp. If that were the ideal, we would transport patients to boot camp, not to the hospital.

The assessment has not been affected, only the documentation and the addition of the IV lifeline.