What Were They Thinking?

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Off the top of my head, I’d say they weren’t, but you folks can be the jury.

I was reviewing a report done by a medic who works for one of our client services.  It had already been reviewed by one person who had given it a high infraction score. Which is why it ended up on my screen.

The call was for a person who passed out. The crew arrived and did the usual and correct things. They determined, again correctly, that the patient had a GI bleed. Which is where things went off the rails.

The first mistake was that they decided to remove the patient to the ambulance before the initiated ALS treatment. In some cases that sort of OK, but in this case it’s definitely the wrong thing to do. The protocol calls for immediate treatment of serious conditions at the patient’s side before extrication. Which they definitely should have done in this case.

Why you ask?

Because as documented in their patient care report, the patient’s blood pressure was 74/40. Supine.

So, what mode of conveyance did these paramedics decide to use to get a profoundly hypotensive patient out to their ambulance?

Backboard? No.

Scoop stretcher. No way.

Reeves stretcher. Uh uh.

I mention these three devices because I know that they have them on their ambulances.

No, my friends, our life saving duo chose to put the patient in to their stair chair. Which of course required taking the patient with a profoundly low blood pressure lying supine and sitting him up.

Which, again according to the written report, caused the patient to have a “short period of syncope”.  Of course they didn’t seem to relate the two which is perplexing and concerning since it’s kind of basic medical science.

For my non medical readers, try this. Take a bottle of soda or even water. Consider the bottle cap the head of a person. The neck of the bottle is of course the neck. The rest of the bottle is the rest of your body.

Got that? Good.

Now drink or pour out half of the contents.

Now lay the bottle on it’s side.

You’ll see that some water is still in the area of the cap.

Now stand the bottle up into it’s normal position.

Where is the water now?

The water is blood, the cap is where the brain is. If you stand the bottle up the water goes to the bottom and leaves the cap high and dry.

The same thing happened to the patient when the medics sat him up and put him the stair chair. Which is why he passed out. The resilience of the human body is why he regained consciousness, but I can tell you that his brain took a bit of a beating during the interim. Not to mention the increased demand on his heart.

The most annoying thing about this is that these guys are paramedics. They are supposed to know this stuff. If EMTs did it, I’d still score it as an infraction, but it would be more understandable. But not with paramedics.

I took the report and raised the infraction level and then sent it on to the medical director. Who would have raised it more, but I had maxed out the points.

I can tell you if I were still working on an ambulance and anyone on the call with me had suggested or tried that sort of thing, the results would not have been pretty. When it came to making sure that we didn’t do stupid stuff to patients, I was uh, less than diplomatic.

Not that I can do that since we are a “customer centric” operation using coaching and education to correct errors.

Now I have to go out to the client service and do some remediation for the medic in charge of the call. In a coaching and supportive kind of way, of course.

Some days I just shake my head.

8 COMMENTS

  1. This is more of a QA of documentation and punishment for being accurate? I think a lot of your paramedic crews would have covered this situation up with some shifty documentation. For instance in this situation; I could have documented an initial BP of 100/67 and skin that is w/p/d w/ no SOB. Then when i went to sit him up and he went syncopal. oops! how was I to know that was going to happen? He was fine before i did that. Who can argue? we’re the only two people on scene that know what’s going on. This brings up my question to you. (and it is a question, not a jab at anybody). It’s a general question and no so much a question about this blog (so please don’t focus on the specifics of this article). It seems to me that QA/QI is really just a review of someones abilities to document and has little to do with how much of a paramedic they are. Unless someone is on scene to call them out of course. What ideas/suggestions do you have to avoid this and have a real QA/QI system in place? and do you agree?

    • You bring up some good points and questions, so I’ll try to respond to them.

      First let me explain the company’s philosophy and my approach within that.

      QI is not meant to be punitive. Or should not be. If you take a punitive approach to QI, you will get exactly what you describe. You’ll get boilerplate reports that contain a lot statements that are probably not true. I’ve seen the results of that because some of the medics employed by our client agencies also work part time for other services that take that approach. I see a lot of meaningless information that has nothing to do with patient care, but is obviously there because some one (probably risk management) told them they had to right that. Additionally, a crew that was worried about getting “in trouble” would not have written that they sat a patient up and he lost consciousness.

      We take an educational approach to QI. Which means that in the case we are talking about, I will approach this by asking the medic about the call, what his thought process was, and then discuss why we thought the call needed to be reviewed. We’ll review A&P and why the patient should have been removed supine or as close to it as they could achieve.

      Secondly, we keep this confidential. Even though I blogged about it, the chances of that medic or anyone reading the post knowing specifically what call I’m talking about are pretty much non existent. In addition, when I go to meet with a medic, people will know I’m there, but they won’t know why I’m there. Unless the medic goes and tells his co workers, they won’t know. His chief won’t know, his LT won’ know, even his partner won’t know. The only exception to this would be if someone did something potentially criminal. Which has happened in other cases, but I’ve not had that happen. Hopefully I won’t.

      I do know of a case involving another agency where the medic did an arguably negligent job with a procedure. Which happens and is the type of thing we re educate people on. That wasn’t the problem. The problem was that several days later he went in to their ePCR system and re wrote the report to cover up the issue. Which didn’t work because the system has an audit trail that reported when he did that. So, what would have been re education is now likely to be disciplinary in nature. Not because of the medical error, but because of the fraudulent documentation.

      Within my employers policies and procedures, I take a slightly different approach. If I were a teacher, I’d be an “easy grader”. That is I try to find the lowest level of deficiency that will achieve the goal of getting them re educated. Their medical director agrees with that. As a result, what I refer to as “chicken shit” deficiencies are put aside and dealt with when we do the quarterly agency reviews. If I went out every time that someone forgot to document a BP within the time constraints protocol requires two things would happen. I’d be out there an awful lot. The medics would groan when I showed up and not listen to me.

      That’s what I hated about QI when I was in the field and it’s what every EMT and medic hates about QI.

      Another thing is that we are not employees of the agencies we audit. There are no politics, favoritism, personalities, or other internal BS that goes on when agencies do their own QI.

      I think I answered your question, but I reiterate. If the QI process is seen as punitive, you will get exactly what you describe. I was fortunate enough to work for an agency up until the last couple of years took a non punitive approach to QI. We had monthly rounds where cases were discussed openly, if a problem propped up, people we re educuated or remediated as needed. We could even speak directly with the medical directly or he could speak with us, openly and freely. That changed with a new medical director, who frankly, knows the system well enough to know that the punitive approach would not work. Which didn’t stop her and produced the expected results. But, I digress and that’s a story (perhaps) for another day.

      If I didn’t answer your question, please let me know.

    • EMSA, thank you for your response. That is a better approach and is luckily the current trend in EMS and I really like how it’s an outside third party handling the critiquing, but the problem is that it is still punitive. I mean at some point or at some level of error you would have to step in and punish a person right? So even though there is a laid back constructive criticism approach I’m still looking at being in trouble if it’s bad enough or I do it enough times. Does your evaluation get back to management at all? Say i apply for management or Captain or something to that effect, does the management know that i have problems with my runs sometimes? Even if management tries to understand that it’s expectable it still looks bad compared to the other guy that is also applying that knows how to doctor and word his reports so that he never has to see you.

      You see a lot of people that are horrible at being paramedics. The new way of charting with the billing and the QA stuff is such a big part of the job and such a hassle that these newer medics bust out the laptop on the to the call and start filling out what they can. They don’t pay any attention to driving or the road. They get on scene and don’t bring anything in with them except the laptop. They immediately start filling out more stuff on the laptop next to the Pt instead of doing any sort of exam or interventions. It’s all they can think about. It’s obviously their number one priority. Pt care is a distant second to doing their chart. That medic is always going to look good to a QA review of his chart even though he is horrible. I don’t know what the answer is to a true CQI/CQA process but i’m looking.

      • We don’t do any punishment, we don’t recommend punishment, we don’t get involved in the internal operations of our client agencies. Management will know overall how everyone is doing, but not specifics. We’ll review individual performance with the medics. We’ll show how the agency is doing in comparison to other client agencies, but we don’t identify any of them by name. As I noted earlier, the only time anyone got referred for discipline was when a reviewed call turned out to be doctored. We didn’t even discover that, the employer did when they brought up the report for internal QA review and remediation.

        You’d be surprised at how bad a chart can look even if the medic thinks that they are documenting well and they are in fact ignoring patient care. It’s hard to explain and I’d be giving trade secrets away, but we often catch that sort of thing.

        One other thing I didn’t mention in the article because it wasn’t pertinent. Part of our audit process is to look for procedures that are not indicated by the patient’s condition. Over ALSing is what I call it. Some systems encourage that for billing purposes and sooner or later that’s going to draw the attention of CMS or someone else. We try to keep the agencies and their employees out of trouble. Not that they always listen to us.

        The big problem with QA in EMS is that most systems take a punitive approach. I know of a case where a private ambulance service, not one of our clients, terminated two paramedics because they forgot to sync before cardioverting a patient. No harm to the patient (fortunately) but firing them isn’t going to make other people better paramedics. It’s just going to make them more likely to try to hide errors.

  2. My only issue is that with any of your preferred means of conveyance, unless the patient was in a one-story house, they are still going to be carried feet-first down the stairs. I’m not sure how one is any better than the other.

    • Not in my experience. Properly secured to a scoop (or Reeves) a patient can be brought down either level or slightly head down. A patient in a stair chair can be brought out “backwards” so that their feet are above the level of their heart. If you service would like, for a small fee I’ll come out and do a training session on scoops and other fine extrication devices.

      • I wish I had the money. It would be worth it to see you carry a scooped patient “level or slightly head down” from the third floor of a tenement in Kinda Big City, of which I have many in my Tiny Little Suburb. And do it faster than a stairchair.

        I’m not opposed to expanding the usage of scoops- most EMT students have never seen one outside of pictures, I’m learning- I just question it’s utility in the given scenario considering the limitations of where we often find ourselves.

        • Been there, done that. Sorta Big City has a very high percentage of three decker houses which were built in the early part of the 20th century. Narrow stairs, tight corners, and other obstructions. We used scoops with great effect. It helps to have more than two people, but two people can do it. It might not be faster than a stair chair, but it’s better for the patient. Probably better for the medics in the long run as well.

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