It’s been a bit over eight years since I last worked on an ambulance. Since then the only times I’ve been in one was when I was talking to a paramedic from one of my client agencies.
Mostly what I do is read ambulance reports. Between auditing, doing case reviews with providers, and doing quality improvement for our own auditors, that can be 75 or more a week. Have mercy on my poor eyes.
Sometimes the things I see on a report make me scratch my head. Other times, they make me want to bang my head on the desk. Once in a while I’ll read a report and think “WTF were you thinking!”
It’s not all doom and gloom because truth is that most of the reports indicate that the medic or EMT knew what he was doing and did it properly. Despite what some of the providers at our client agencies may think, we do not get paid more we write up an infraction.
As a friend of mine who is a retired police officer used to say when he was accused of writing a ticket to meet a quota, “We don’t have quotas, we have all the business we can handle as is.”
Anyway, here are a few of the recurring themes I see when I read reports. I mention these as pointers and tips for medics to keep in mind. Sometimes, in the heat of a call, it’s easy to forget something basic that needs to be done.
That’s why it’s good to rehearse in your mind what you are going to do when you contact your patient. Keep in mind that all of the various Emergency Medical Dispatch systems are imperfect. They will tell you that they are, but nothing involving humans talking over a telephone is perfect.
So, here the the things big and small that I see and which give me an “Ice Cream Headache.”
Universal Blood Glucose Checks. My state’s protocols are quite clear on when those should be done on patients. 1) Altered Mental Status. 2) Suspected Stroke.
Those both make a lot of sense. AMS covers a lot of territory, so there is some degree of latitude. For example a person who is suspected of being drunk could be a diabetic with hypoglycemia. You don’t want to be the medic or EMT who sent a person off to a jail cell because he was “Just a drunk.” only to find out that he died from hypoglycemia. That is, as we say, a career limiting move.
The Stroke protocol is also clear. Very similar to the “Just a drunk.” scenario is thinking that someone is having a Stroke, calling a Stroke Alert and then finding out at the hospital that they were hypoglycemic. That’s not as bad as the first scenario, but you are going to get a talking to from someone.
With that having been said, some EMTs and medics seem to think that the only needed indications are that the patient has finger and the provider has a lancet. I can’t for the life of my understand why a 20 year old man who twisted his ankle and needs a trip to the hospital should have his Blood Glucose Level checked. Even if he is a diabetic, if he is sitting up talking to you, makes sense, and has no indication that he is in need of Glucose, there is no reason to stick a needle in his finger so that you can get a number to put in your report.
A more serious issue is treatment of hypotensive patients. When I read a report that says that a patient, especially an older one, has a very low blood pressure and the next sentence says that the crew picked the patient up and sat him in a chair, I know what to expect the next line to say.
It will often, but not always, say that the patient became dizzy or passed out. The medic always seems to be mystified that this happened. In a recent case a crew did that and the patient not only passed out, but he went into cardiac arrest. Where he stayed despite their best efforts.
I am not saying that sitting that poor man with a blood pressure of 78/50 up is the proximate cause of his demise, but I won’t be surprised if a personal injury lawyer does. Fortunately, I have never been called to court to testify about a call I audited. At least not yet.
Now, the city I worked in had and still has some older housing stock. Some of that goes back to the years before World War 2. Well before. Buildings with three stories and no elevator are the norm. Buildings with four or five stories and no elevator are not at all unusual. As a result I know what a pain (literally) it can be to carry someone down narrow stairs that have a lot of twists and turns. Believe me, I feel the effects of over more than 30 years of doing that every morning when I get out of bed.
Still and all, there is a proper way to move a hypotensive patient and a wrong way. The proper way involves a lot more work, but it’s better for the patient. Which is what we are supposed to be here for.
There is a section of the basic EMT course that covers “Loads, Lifts, and Carries.” It’s fairly early in the program and it’s rather important. EMT students learn the proper way to move patients, restrain (for safety) patients, carry patients, and get them in and out of the ambulance. It’s not mentally difficult, although it can be physically.
As a result, every EMT and paramedic knows the proper way. So, they can’t claim bad training. They can claim bad education if no one every taught them the physiology of shock, but that’s covered in EMT programs as well.
So, my default position is that they are lazy. Pure and simple. Of course, I can’t write that in a review. I have to keep the language pretty dry.
“Patient was found at contact to have a BP of 78/50. Medics sat the patient up and placed him in a stair chair. Patient became unconscious.” Pretty dry, but all but the dumbest person can understand what that means.
Okay. I’m a bit over 1,000 words so I’ll post part 2 tomorrow or the next day.