Patient Advocay

[ZombieEMT]

Since day one of being an EMT, I have prided myself on being an advocate for my patients and community. New Jersey offers a different approach to EMS with its tiered system. The issues I have observed is that many EMTs are afraid to advocate for themselves or their patient, because they are afraid to question a decision by an ALS provider. Today is an example as to why its necessity.

BLS and ALS dispatched for a 75 year, possible CVA. Upon arrival patient is unconscious with snoring respiratory effort, VS HR 106 RR 10 SaO2 74% BP 140/90. Hx of CHF MI DM HTN CAD CVA.

The suprise was when I examined pupils and they were pinpoint. When I asked the wife about pain meds, she says he takes oxycodone but she administeres and didn't today. However patient does have access. ALS initially stated no to Narcan and wanted to RSI, because they were familiar with the patient and his other medical issues, in addition to his age. Also said no because wife said she didnt give oxy. I said this looks like an OD and has possibility of being an OD. I said why not give Narcan now, and if it doesn't work by the time we get out of house, get orders and draw meds, they can RSI. I even offered to administer out of BLS supply and take responsibility. They agreed to that. By the time he was in truck. He was conscious with normal respiratory effort.

I got kudos from the ALS team and it felt good. But it felt good because I did right by my patient. I know many EMTs that would not have picked up on that and had they felt it, would have never spoken up.

 

[NomadicMedic]

In my system, the EMT would have given the Narcan and canceled the medic.

 

[RocketMedic]

Zombie, you did good. And in this case, a titrated dose of narcan is a reasonable intervention. Personally, I'd call this a classic ALS patient, but if Narcan fixes the problem, I'd be OK with it going competent BLS.

A lot of the anxiety regarding "countermanding" ALS comes from the perception, real or imagined, that 'needless' activation/use of ALS resources will threaten current and/or future relationships with those ALS providers, to include employment, or current employment. For those reasons, I think it's critical that tiered systems have strong protections for BLS providers to prevent retaliation and the expectation of ALS providers that they are servant leaders, not lords of the fief.

 

[Carlos Danger]

Since day one of being an EMT, I have prided myself on being an advocate for my patients and community. New Jersey offers a different approach to EMS with its tiered system. The issues I have observed is that many EMTs are afraid to advocate for themselves or their patient, because they are afraid to question a decision by an ALS provider. Today is an example as to why its necessity.

BLS and ALS dispatched for a 75 year, possible CVA. Upon arrival patient is unconscious with snoring respiratory effort, VS HR 106 RR 10 SaO2 74% BP 140/90. Hx of CHF MI DM HTN CAD CVA.

The suprise was when I examined pupils and they were pinpoint. When I asked the wife about pain meds, she says he takes oxycodone but she administeres and didn't today. However patient does have access. ALS initially stated no to Narcan and wanted to RSI, because they were familiar with the patient and his other medical issues, in addition to his age. Also said no because wife said she didnt give oxy. I said this looks like an OD and has possibility of being an OD. I said why not give Narcan now, and if it doesn't work by the time we get out of house, get orders and draw meds, they can RSI. I even offered to administer out of BLS supply and take responsibility. They agreed to that. By the time he was in truck. He was conscious with normal respiratory effort.

I got kudos from the ALS team and it felt good. But it felt good because I did right by my patient. I know many EMTs that would not have picked up on that and had they felt it, would have never spoken up.

Good job.

This ALS crew needs some re-training, because they got the clinical reasoning exactly backwards here. If a history of MI, HTN, CAD, CVA isn't enough to make you strongly prefer to avoid intubating, you don't know what you are doing.

 

[ZombieEMT]

Zombie, you did good. And in this case, a titrated dose of narcan is a reasonable intervention. Personally, I'd call this a classic ALS patient, but if Narcan fixes the problem, I'd be OK with it going competent BLS.

A lot of the anxiety regarding "countermanding" ALS comes from the perception, real or imagined, that 'needless' activation/use of ALS resources will threaten current and/or future relationships with those ALS providers, to include employment, or current employment. For those reasons, I think it's critical that tiered systems have strong protections for BLS providers to prevent retaliation and the expectation of ALS providers that they are servant leaders, not lords of the fief.

I was not even arguing Narcan to get rid of the ALS. They arrived on location at the same time, and did an ALS treat anyway. I think for my partners, as well as the ALS provider, the precaution for them to stay after Narcan was warranted because of his age and history.

What I will say about BLS having protects against retaliation of ALS, is that its not really a concern to me. Many EMTs are afraid to speak up and get their peepee slapped but generally thats as far as it goes. Many times, the BLS and ALS are not from the same employer, so they have no authority other than level of care. Even in systems where the BLS and ALS is the same, many times the medics are not considered supervisors. When it comes to push and shove, they can not formally reprimand us, they don't dictate organization policy, and they can't tell me that I can't talk to my patient (which has happened).

I feel like some providers also get a god complex, and the EMTs that do not speak up for themselves and their patients contribute to it. The EMTs that let the higher providers (such as medic) walk all over, are who the ones giving them the idea that it is okay behavior.

 

[E tank]

The ALS team, at least, didn't stand on hubris and step on their johnsons over the whole deal. That's worth mentioning. They got it wrong but were at least willing to be shown wrong by the BLS team. Seen that go the other way many times...

 

[DrParasite]

If it walks like a ducks, talks like a duck, should you treat it like a duck? Is there really a downside to treating this as a suspected OD, and if no response to narcan, you can always RSI (will the narcan administered prior interfere with the sedative or paralytic? not sure, someone help me out with that)

I've worked for agencies that had both ALS and BLS units, as well as ones where ALS was a separate agency than BLS. In either case, it's very rare that the paramedic is my supervisor, although they are a high level of clinical care, in theory, a more knowledgeable provider, and one who has more tools at their disposal.

Intubation, especially an RSI intubation, on an old and historically sick person has the bad habit of them never coming off the tube. Do it if you need to, but if you can avoid it, it's generally better for the patient.

Arguing with a fellow provider on scene in front of a patient is never a good thing. I have had discussions with paramedics after a call. And I also know there are paramedics that walk on water, are never wrong, and never makes mistakes (just ask them). Those I try to avoid, but I also know my limitations, and sometimes those are the ones who show up to help. and I'm experienced enough and competent enough to know when to make a big deal about something that a paramedic is ignoring. And to quote Bill Murray, "If I'm wrong, nothing happens! We go to [sit in the corner and think about what we did]- peacefully, quietly. We'll enjoy it! But if I'm *right*, and we *can* stop this thing...."

It's tough for newbie EMTs to question paramedics, because they don't have any experience to know any better. And many are taught that paramedics know all, and when in doubt, call for ALS. Will you piss off a paramedic if you question him or her? yep, been there and done that. also sat in the corner once or twice. But when your right, and your advocating in the patient's best interest, and standing up for yourself appropriately.....

 

[Bullets]

In my system, the EMT would have given the Narcan and canceled the medic.

In a lot of systems in NJ it would be to. Dont know why the medics wouldnt want to give narcan, once they wake up they could have released to BLS.

But also if they were setting up for RSI and giving HFNC and bagging, which they should have been based on those vitals, he probably would have woken up anyway

 

[SpecialK]

In the past it was the norm for more senior personnel not to be questioned, indeed, it was expected you would not question them.

With the move away from the old vocational system to tertiary education, there has been a significant decrease in the average age of staff and a much improved culture, The ambulance service I saw as a student a decade ago is fundamentally different than that of today. When I did nursing before I saw much the same problem; particularly from the older staff.

The psychology of why this occurs is actually quite interesting.

A much more CRM focussed way of doing things is now the norm. Indeed, and I say this with some caution, if you don't speak up when you clearly see something is wrong, then you are likely to be just as culpable as the person doing whatever it is. This is especially true with formal external registration being introduced soon. Obviously a volunteer or less experienced junior crew is not going to be hauled over the coals to the same degree as a more experienced or higher ATP person. The last CPG update included a formal section on CRM and this is now taught as part of CCE.

 

[joshrunkle35]

If a paramedic can’t explain/teach in plain terms why they disagree with an EMT’s course of action, they shouldn’t disagree.

I’m fine with a paramedic that looks up the physiology with an EMT after the call because they cannot remember specifics. But, I just can’t stand paramedics who take control because they are a medic and then will not give voice to their actions other than, “Trust me, I’m a Paramedic”.