Can one man really activate every EMS unit in the city?
It's a cool, sunny day in New York. The first snow flurries of the season (occurring in January!) had fallen the night before, leaving the streets wet, but just the fainted hint of white under the trees. The time is just past 1PM.
BEEP BEEP BEEP BEEP!!!!!
"Fair Lady, Fair Lady! Respond to the School of Social Work for a woman passed out!"
"Ummm, Medic 1 to Base, is the patient breathing?"
"Stand-by Medic 1!"
...two minutes later...
"Medic 1: Patient is breathing!"
"Ummm, thanks. 10-4. Fair Lady arriving."
By the way, in case you haven't yet figured it out, it is going to be one of those calls.
We arrive on scene to find our patient, a 63 y/o female, who was reported to us as passed out and in the lobby, already gotten up and traveled to the 7th Floor. Sooooo.... off we go! My crew and myself get off the elevator, through a couple glass doors to find the patient smiling and yelling:
"Oh you guys! No. No. No. Enough. I'm fine. Go away!"
Definitely one of those calls. My partner (and CCiT -- that is, Crew Chief in Training) approaches the patient. He quickly makes no headway. Intervening slightly, I steer the patient and my crew into a conveniently empty conference room. My partner directs the Probie (did I mention my crew comprises of FOUR people!) to start getting vitals. The patient puts up some fight, but quickly sees reason and lets us check her BP, etc. as my partner persuades her.
"Come on, I don't need this! You guys were here two years ago! I feel fine now," she says.
"Huh?" I think. "What happened two years ago?"
"Oh, I passed out, right over there," she points. "I went to the hospital and they told me I was having 'mini-strokes.' I'm also diabetic."
"Great."
My partner gets the rest of her history. Unfortunately, our patient has gotten even more vocal, and worse, when my partner suggests she takes a ride over to the hospital, she refuses, adamantly. I take the opportunity to pull my partner off to the side and remind him of the presenting problem's link to her Hx. Now, at this point in the game (Warning! Rant alert!) I would normally do a quick finger stick (and so would every other EMT on the planet) and check her blood sugar. After all, she did say she missed lunch today. Too bad. New York City BLS units aren't allowed to carry glucometers.
So instead I tell my partner to call Med Control and ask for a recommendation. Since the patient is under 65, Med Control physicians don't have authority to force the patient to be transported, but I figure what's the harm. I want to take her, but I don't want to get in a fight with the patient. I figure with a doctor's recommendation and the moral authority to pursuade the patient to spend a $50 co-pay, she'd be more willing to go. Little do I know. The Medical Control Doc orders us to transport the patient. Unwittingly, I have now entered a very, very, gray zone.
At this point, the Patrol Captain of the University's Public Safety Department strides in the room.
"Virginia," he begins (Name changed to protect Pt. con.) "you realize that you're on private property. If the Medics" (by the way, that's just the street name for Fair Lady personnel. We're all just EMT-Bs) "want you to go to the hospital, I can..."
I cut him off. I know where that statement is going, and the last thing I want is to force the patient to the hospital. I want her to want to go to the hospital. Besides, I can always call PD. I have a valid order saying I need to take her, I think. It also becomes increasing evident that my chances of convincing my patient to take a ride with us are becoming less than nil faster and faster.
"What do I do!" I think at myself... and in a moment of EMS competency I remember my protocols: "...care can only be transferred to a medical authority with a higher level of care."
Aha! This is what ALS was designed for. Sorta. Well, it'll do the trick regardless. While, I no longer have the authority to RMA, and ALS rig still does. So I get on the horn and call MARS and request an ALS bus to our location. I decide the patient is in the good hands of my partner. I go downstairs and await our backup. 10 minutes later, a BLS rig pulls up. @&%#! I approach. I speak. They speak. I call MARS again, reinstating my request for ALS. I am informed that since I already have a BLS bus on scene, they are the ones who need to request ALS. I remind the nice man on the other end of the phone that I am a BLS bus. The nice man tells me to pound salt. I look at 16-E and tell them what MARS told me. We both roll our eyes. 16-E decides he wants to make contact with my patient. We go upstairs. 16-E talks with the patient. He asks me, "Do you want me to call the Conditions Boss?" Me, never ever having heard of an entity known as the Conditions Supervisor says, "Huh." I seem to be doing that more than usual today.
The Conditions Boss, 16-E informs me, is an FDNY dude who solves situations just like ours. Awesome. I grant him permission to proceed.
"16-E to Central. Request Conditions Boss at this location."
"16-E! No Conditions available in the vicinity. Will you take an ALS unit instead?"
Mon dieu! 16-E looks at me. I nod.
"16-E. Go ahead. We'll take an ALS unit here."
"10-4. 24-U respond to....."
Let's go over the cast currently on stage:
-1 patient, hereknown as Virginia.
-1 concerned friend, female.
-2 crew members, BLS unit 16-E
-1 Public Safety Patrol Captain
-3 random extras, assorted genders, looking through the window into the conference room
-4 Fair Lady crew members
Basically, we're all looking at each other.
Final Act
"16-E! 16-E! Pick it up!"
"16-E."
"Conditions Boss is now available. I've sent him to your location."
Enter 24-U, the ALS unit. We fill them in. We also simultaneously hear the Conditions Supervisor pulling up to the front of the building. I take a quick peek out the window and see:
-Public Safety Patrol Car
-Fair Lady Ambulance (Type III)
-Conditions Car (Ford Excursion)
-16-E Ambulance (Type II)
-24-U Ambulance (Type I)
All blinkies going strong.
The Paramedic goes, "What's your blood sugar?" Patient sticks herself with a meter that I have now determined she has had on her person all along.
Patient: 132
Paramedic: Right. Good! Well, finish your lunch, sign here, and we'll all leave.
Patient: Great!
Handshakes all around.
We all pack up and take the elevator down. As we're leaving, I'm not quite convinced the paramedics did everything they should have, especially since on the way out the door I'm stopped by a coworker of Virginia's. He states that the present incident is actually the second in a row. An earlier episode having occurred an hour before we started this call. I'm concerned, but I shrug, and head back to the vehicle. I've already passed care to a higher level.
What are your thoughts? What would you have done?
2 comments:
Here's what I would do...
-ALS should have been dispatched from the initial call, due to possible loss of consciousness
-while you are correct that under 6? and over 65 in NYC requires telemetry for approval of RMA, legally, this is not required, the patient must only be AAOx3 and aware of the severity of the situation as well as the consequences up to and including death, you must also inform the patient of their transport options. Telemetry is there to make sure these criteria are met and also to try to convince the patient to go to the hospital. In this case, telemetry must not have thought she was AAOx3 or aware of the consequences. Either way, it puts you in a very difficult position.
-If I were the ALS unit, I would have first done a thorough physical exam and history of present illness, checked a 12-lead, done a full neuro exam, orthostatic vital signs, blood glucose.
The thing is, her normal BG could probably have been established just by looking at her and talking with her. I would be more concerned about arrhythmia, CVA, intracranial hemmorhage, hypovolemia, etc... things that can cause you to pass out, but may have no obvious signs/symptoms when you look at her.
One tip I would also give would be to try hard to avoid talking about transport decisions until you have completed the basics (SAMPLE, OPQRST, physical exam). This will give you a more solid foundation to argue for transport to the hospital.
I would have also returned to try to convince her more after finding that this was her second syncopal episode.
I definitely see the problem. I recently encountered a similar situation in which a woman passed out, hit her head on the way down, etc. ALS beat up to the punch and she already signed their release form. They said that because they were higher medical control they had the power to release us without our need of examination. A similar gray zone was crossed. My point on this is that the state has granted them a higher medical knowledge and control. If the patient signs their release form...does it necessarily release us at the same time, or does is allow the refusal of ALS assistance? On this one, I think I would have strongly insisted on her going, then upon the recpection of the second episode, either had the PD or Med Control demand that she be brought in. It's a doozie, no doubt about it. Best of luck from here on out!
Dave - NJ EMT
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