Being denied orders by medical control

[thegreypilgrim]

Surely, the primary function of online medical direction is to be an aid to the paramedic in the field. I mean at a fundamental level, that's what online medical direction/control is all about right? It's supposed to facilitate the provision of clinically appropriate therapy in the field.

What it isn't supposed to be, or so I would imagine, is part of the problem. It should not become yet another barrier or obstacle which must be navigated around in an already hectic situation.

I'm not saying the paramedic is supposed to have carte blanch or that it should be an uncritical process, but surely if the paramedic is calling in it means that "serious business" is going on (unless you work for my service where you just have to call for everything...but even then if the medic is actually requesting orders and not simply reporting it suggests it's a more serious call).

How often, however, do we hear "just transport, recontact with any changes" and then just static or a dial tone? This is especially problematic in areas such as mine where physicians have delegated RNs as surrogates (MICN or "Mobile Intensive Care Nurse"....a misnomer if I've ever heard one) to provide limited medical direction. Most of the time this turns into a pissing match with one party feeling empowered over the other (I'll let you figure out the order there) coupled with an eternal, incorrigible unwillingness to deviate from protocol.

Is this a problem with your service? Or is this just another in a long list of intractable problems native to California?

 

[NomadicMedic]

Sounds like another California "we don't trust our medics" problem.

All of my base station contact is for consultation and trauma advisory notification.

The ONLY thing I have to call and ask permission for is TNK. Every other drug and procedure is covered by standing orders.

Of course, if I'm stymied or want to go off the page, I'll call a doc (NOT a nurse) for consultation. If my treatment plans are valid, I will not be denied orders.

It's nice to work in a system where the medics are allowed to practice critical thinking and decision making and are treated as professionals.

 

[abckidsmom]

This is not a problem in our area. In my experience, difficulty getting a medical control physician to agree with your plan for treatment or recommend depends on your ability to convince the physician that you are a reasonable or intelligent person.

I'm not at all saying that you are suffering from that problem, just saying what puts the breaks on our conversations. I notice when I let an unsure preceptee talk to the dr, things go less smoothly...if it's not going well for the patient, I take the phone and talk to him.

 

[TransportJockey]

My service's protocols I think have 2 areas where it says contact medical control for permission. And even then we are allowed to do those when out of contact with base (which is a lot of places in our county). Our medical director trusts us to be able to do everything he has authorized us to do in our guidelines.

 

[Veneficus]

Nowhere I have ever worked, even from my earliest days have I ever been denied orders.

I agree with the earlier posts, it is about presentation and your reputation as a provider.

Many of the med control docs I know tell me they deny orders as a matter of routine on anyone who calls and asks for something covered in standing orders. They figure if you can't make decisions based on your protocols, then you stay firmly on the map.

I have also noticed that many doctors get really annoyed when you have very restrictive protocols and have to call them all the time. They get so many calls they just don't want to hear or think about what the medic is saying, so they simply say "no."

I have never worked in a state where a doctor could delegate authority to give orders to a nurse. In all fairness though, one of the states I did work in now allows it, but that was after my time.

California seems to have many issues with its medical licensing and other aspects of healthcare though.

 

[socalmedic]

yes, i have been in that pissing match before. yes, the micn actually hung up on my as i was asking for orders. went something like this...

me, "...full report..., calling for pain control orders"
micn, "copy, transport recontact if there are any changes"
***dial tone***
me, one attempt to re contact, no answer after 6 rings. yes communication failure protocol, I GET TO THINK...

the micn was not happy when I arrived and she found out that i went on com failure (yes i did the silly paperwork). she turned in a complaint with the PCC (paramedic care coordinator) and started an arguement with me in the ER about who gave me orders for 20mg MS, and accused me of trying to kill my PT, who was a 78yo with bilateral hip fx. might i add the patient was AOx4 with no mental changes or resp depression, and STILL IN PAIN after 20mg.

i hate the CA MICN set up. Now if i want orders i just ask for the doc when I make initial contact and i get what i want 90% of the time.

 

[JPINFV]

Now if i want orders i just ask for the doc when I make initial contact and i get what i want 90% of the time.

I was going to ask if that wasn't an option for the paramedics with crudy base stations or if you all have tried to escalate the issue to the LEMSA.

 

[mgr22]

Surely, the primary function of online medical direction is to be an aid to the paramedic in the field.

I'd say a higher priority would be to aid the patient by directing the medic.

 

[Aidey]

The last time I was denied orders, I wasn't even really denied orders.

SNF patient, with a guardian through one of those paid guardian services. Had a fever, responded to tylenol, also had a legit palliative care + DNR form that says on it "Pt prefers not to be transported. Contact medical control to determine transport necessity".

Pt has a j-tube, was just put on antibiotics less than 24 hours previous for pneumonia. The facility checked her temp, gave her tylenol and when her temp wasn't down in 30 minutes called 911. By the time we got there and got the paperwork sorted out and rechecked her temp it was an hour after the tylenol and her temp had come down.

Anyway, everyone agreed that it was ok to leave the patient at the SNF, except the ER doc. Her reasoning was that the patient needed to be evaluated to see if they needed antibiotics. What was funny was that the doc that did end up seeing the patient at the hospital was like "Why did you transport?".

 

[thegreypilgrim]

yes, i have been in that pissing match before. yes, the micn actually hung up on my as i was asking for orders. went something like this...

me, "...full report..., calling for pain control orders"
micn, "copy, transport recontact if there are any changes"
***dial tone***
me, one attempt to re contact, no answer after 6 rings. yes communication failure protocol, I GET TO THINK...

the micn was not happy when I arrived and she found out that i went on com failure (yes i did the silly paperwork). she turned in a complaint with the PCC (paramedic care coordinator) and started an arguement with me in the ER about who gave me orders for 20mg MS, and accused me of trying to kill my PT, who was a 78yo with bilateral hip fx. might i add the patient was AOx4 with no mental changes or resp depression, and STILL IN PAIN after 20mg.

This sounds disturbingly like the last time I called base (I work for an IFT service, so it's rare that I ever have to do that, but when I do...my God, it's like a Wes Craven film).

35 year old female with mid-shaft femur fx and history of IV drug abuse and opiate dependence. Received 32 mg MS in the ED prior to transport. Still in tremendous pain being exacerbated by crappy gurney plus extremely bumpy roads. I call in to ask permission to give a measly 10 more milligrams of MS which I was extremely careful to explain was to be given in 2-4 mg increments titrated to pain relief and wasn't going to be just 10 mg given all at once. MICN flips out, says (over the air) that I'm going to knock out the patient's respirations and says no. I repeated my previous statement that the patient was alert & oriented, currently breathing around 20/min. with 100% SpO2 on room air. MICN puts me on hold for 15 minutes while she tracks down the ER doc. Eventually she comes back on the line, says I can give 5 mg. Of course, by that time we were at the receiving facility...

Our county no longer has a communication failure protocol, by the way.

i hate the CA MICN set up. Now if i want orders i just ask for the doc when I make initial contact and i get what i want 90% of the time.

It's an absolute nightmare, and causes far more problems than it resolves. Man, I'm pretty sure if I asked to speak with the attending right off the bat I'd get my head ripped off.

 

[thegreypilgrim]

I was going to ask if that wasn't an option for the paramedics with crudy base stations or if you all have tried to escalate the issue to the LEMSA.

If I tried bypassing the MICN to speak directly to the attending I think I'd be buried next to Jimmy Hoffa.

I dropped the idea of bringing this to the LEMSA's attention when I actually attended one of the PMAC (prehospital medical advisory committee) meetings. Not a single representative of any field provider agencies were in attendance - the entire committee was comprised of physicians, nurses, and administrative personnel from the various base hospitals and trauma centers. Truly eye opening experience as well.

 

[Epi-do]

I've only been denied orders once, and given the ER we were transporting to, I wasn't surprised that it happened. It was a teenage girl that had dislocated her knee cap, I had maxed out the amount of fentanyl I could give through standing orders & had requested orders for an additional 50 mcg every 5 minutes for pain, provided she continued to have adequate respirations & maintained an appropriate blood pressure. Once I got to the hospital, I found out it was denied because the pt was 16 & the doc was concerned about accidentally overdosing her. I felt bad because the girl was still in horrible pain, but I couldn't do anything about it. Had her mom opted to go to any other hospital, I would have been given the orders to do it.

Of course, this is the same hospital that wants us to call for every single transport we bring them. It is my least favorite ER to have to go to, but is also the closest to our district. Needless to say, that means we end up going there alot.

 

[socalmedic]

Our county no longer has a communication failure protocol, by the way.

It's an absolute nightmare, and causes far more problems than it resolves. Man, I'm pretty sure if I asked to speak with the attending right off the bat I'd get my head ripped off.

I am not a medic in LA, nor will I be (well maby for cash on the side). I am however an EMT in LA, and a PT medic in a county that has a decent EMSA. and yes the nurses do not like me, but they have to pretend to because the docs do...besids there isnt much they can say. in that county if the bed wait is more than 15 min redi net sends an email to EMSA and they get a fine :unsure:

JP- yes, as a medic you are working under delegated authority of the MD, we have the RIGHT to demand a physician, the MICN is simply a convince for ME if I dont want orders. if I dont agree with the MICN orders I do not have to follow them. I also wait untill I have a 5min eta to make contact because once I do make contact I have to re-contact prior to any treatments, in CA early contact is DETRIMENTAL to my ability to treat a critical patient.

 

[ffemt8978]

Sounds like another California "we don't trust our medics" problem.

All of my base station contact is for consultation and trauma advisory notification.

The ONLY thing I have to call and ask permission for is TNK. Every other drug and procedure is covered by standing orders.

Of course, if I'm stymied or want to go off the page, I'll call a doc (NOT a nurse) for consultation. If my treatment plans are valid, I will not be denied orders.

It's nice to work in a system where the medics are allowed to practice critical thinking and decision making and are treated as professionals.

I agree, it's nice working with a Medical Director that is willing to be more progressive with his protocols. I also like that fact that when I call in and say I need to speak to medical control, other than a preliminary report about what's going on so they can give the doc a heads up, I don't deal with nurses. The doc is usually on the phone within one minute.

 

[DrParasite]

Many of the med control docs I know tell me they deny orders as a matter of routine on anyone who calls and asks for something covered in standing orders. They figure if you can't make decisions based on your protocols, then you stay firmly on the map.

ehhh, that kinda sucks. not that I don't see the doctor's point, but it sucks.

I have also noticed that many doctors get really annoyed when you have very restrictive protocols and have to call them all the time. They get so many calls they just don't want to hear or think about what the medic is saying, so they simply say "no."

sounds like lazy doctors. not the medic's fault the protocols are restrictive, and it sounds like the medics want to do more to help the patient, and the doctor won't let them. who cares if they get called all the time, that's their job. don't like talking to the medics, find another job, or don't take a position that requires you to be the medical control doctor.

Our county no longer has a communication failure protocol, by the way.

really? so if you have a sick patient and you can't reach the doc, you are limited to just your standing orders? can't give more pain meds or anything? that sucks

 

[DrParasite]

JP- yes, as a medic you are working under delegated authority of the MD, we have the RIGHT to demand a physician, the MICN is simply a convince for ME if I dont want orders. if I dont agree with the MICN orders I do not have to follow them.

can you elaborate on this? I thought only a doctor could give you orders, not an micn, since it is the doctor's license you are operating under (hence the reason the doc needs to cosign charts). I know different states have different rules, but what training does an micn have over a regular RN? and you can call for orders and get an micn and ignore them if you want to? sounds like an recipe for chaos.

I also wait untill I have a 5min eta to make contact because once I do make contact I have to re-contact prior to any treatments, in CA early contact is DETRIMENTAL to my ability to treat a critical patient.

how can that be? a doctor knows far more than any paramedic. they know more about every drug and how to do an assessment, as well as have other ways they can administer it. At least that was what I learned by reading another thread.

on a less sarcastic note, I am surprised by this statement. i would think the worst thing a doctor can say is "IV monitor and transport" which pretty much a do nothing order. I can't see it as being really detrimental, just not beneficial.

 

[socalmedic]

so if you have a sick patient and you can't reach the doc, you are limited to just your standing orders? can't give more pain meds or anything? that sucks

in all honesty there is not much in LA to do, the closest receiving is 15 min max unless you are in gorman and antalope valley. what i think is retarded is the pain management, 2-4mg prior to contact wtf. at least i have 10mg and repeat 10mg on com failure.

here is the firefighter proof prior to contact card for la county. PDF

 

[socalmedic]

drparasite- the MD has given the MICN protocols to give orders to the medic. for instance, "if Pt.A is hypotensive with no other injuries and the paramedic request Dopamine, authorize dopamine drip 5-20mcg/kg/min starting at 5mcg/kg/min titrating to effect." the MICN is about 100hr on top of RN and they have to do a 12 hour ride along every 3 months. but yes if the MICN gives me orders based on their protocol that I do not agree with I can either withold the treatment or request to speak with a physician. in California you WILL NOT speak with a MD unless you specifically request to.

If an MD tells me to do something I am not comfortable doing I will tell him why I feel it is inappropriate and if he insists that I perform what ever action i will.

 

[JPINFV]

can you elaborate on this? I thought only a doctor could give you orders, not an micn, since it is the doctor's license you are operating under (hence the reason the doc needs to cosign charts). I know different states have different rules, but what training does an micn have over a regular RN?

As someone who's sat in on a number of radio calls, essentially the MICN takes the report and then follows along a flip card system to ensure correct directions. Some things require a MICN order and others require a physician order. Since MICNs are licensed by the state EMS Authority and have authorization from the Local EMS Agency (the regional/county EMS authority), why would this not be allowed?

and you can call for orders and get an micn and ignore them if you want to? sounds like an recipe for chaos.how can that be?

There's a fine line between "ignoring" and "Well, she didn't really answer my question, so I'm going to call back. Oh, they're not answering? Com failure." In other words, the MICN should have picked the phone up.

a doctor knows far more than any paramedic. they know more about every drug and how to do an assessment, as well as have other ways they can administer it. At least that was what I learned by reading another thread.

True, but EMS providers shouldn't need to have their hands held all the way through a non-complicated patient encounter and shouldn't have to have their hands held through most of the complicated patient encounters. Yes, physicians know more than paramedics, but that doesn't mean that paramedics are necessarily blithering idiots, or that they should be treated as such.

on a less sarcastic note, I am surprised by this statement. i would think the worst thing a doctor can say is "IV monitor and transport" which pretty much a do nothing order. I can't see it as being really detrimental, just not beneficial.

If treatment is beneficial, than compared to the treatment, non-treatment is detrimental. Is your baseline for comparison what the patient should be following treatment, or how the patient presents?