As EMS/PHC Providers; Are We That Lazy?

[Richard B the EMT]

The issue with the 2 exemplars were the Providers didn't complete a Call Report. 2 things that Providers perform on a daily basis is NOT covered in class are:

PCR WRITING

and

DRIVING AN AMBULANCE

Not covered in depth. That's the issue....

Say what? I spent 2 days in my initiation class, and had refresher sessions over my 25 years in municipal service, on how to write a call report. I also spent a week in mid july heat on the runway at Floyd Bennett Field, where I had EVOC. I thought we worked for the same system?

[NYCEMS9115]

It is the failure to document properly and/or completely. That was the downfall of the Providers in the 2 incidents. They could be great Providers. Valedictorians in class. Recipients of numerous Service Awards, Received the key to their respected City. Published articles in EMS. Pioneers of the industry. All that doesn't negate that they didn't complete the task at hand; paperwork documentation. That is all.....

RichardB; ask any new NYS EMT #300000 or higher; if they received EVOC and PCR writing in their original course. How many rotations did they do; which one? ER or Ambulance. Most will tell you something which will make you go "Huh?!?"

I have first had experience. I teach Medic Students at a College; many are new EMT's #385000 and higher. They tell me first hand I didn't learn that in school. I have many new hires number #380000 and higher, fresh out of school who don't know how to write a basic PCR and do not know how to operate an Ambulance. That is my arguement with NYS DOH EMS. Some course go above and beyond the State requiremnt; many just stay on par with the State and to tell you the truth par is not good. NYS doesn't ask for much...

We do work in the same system who have gone downhill over the last decade.

Edited April 16, 2011 by NYCEMS9115

[HERBIE1]

Clinical error is unavoidable, regardless of whether you are a Paramedic or a Consultant Physician, to say Ambulance Officers are unable to make rationalised clinical judgement about who should be transported and who should not because "they're not doctors!" is invalid.

As for our guideline for non transport:

Clinical Procedures:

Ambulance Operations Manual:

We had a long discussion with our Clinical Management Group about five years ago and it was said then it is not practical or necessary to transport every patient who calls for an ambulance to hospital.

Kiwi-

Thanks for posting this. Clearly your system is more progressive than many around here. Our profession has evolved over the years- from basic treatment and simple transport to advanced procedures. There were no provisions such as the protocols you listed. Our job was simple- treat and transport, with the occasional refusal. Because our system has become so overwhelmed in recent years, I think policies such as yours are inevitable- for the sake and viability of the providers as well as the hospitals. Will this happen any time soon? Nope- not until we see tort reform.

This is not about being lazy, it's about proper utilization of resources. People seem to forget about the "E" in EMS. If time, money, personnel, and space at ER's were not an issue, then policies such as yours would never be necessary. If we are morphing into more of a public health/.primary care role, then it means major changes need to occur in the whole system. Education, equipment, staffing, pay, credentialing, protocols, public service announcements- it would be a huge shift in how we view and provide prehospital care. The rest of the system would also need to be changed.

Example:

In this area, a couple years ago, a large teaching hospital opened multiple satellite outpatient centers around the neighborhood to help alleviate a severe overcrowding in their ER. They provided PSA's, ads, and plenty of explanation as to the location and purpose of these facilities. As with most ER's, many of the patients they saw were not emergent, or had any acute issues but flooded the ER nonetheless. The ER was(and still is) forced to divert ambulance transports every single day- often multiple times within a 24 hour period. When their clinics opened, the population was up in arms about how this was somehow downgrading the care they received, and since the residents of the area were black and poor, they of course saw this change as being racist and unfairly targeting the poor. The clinics went severely underutilized- people simply preferred the idea of allowing someone else to make their decisions for them. The ambulance ride, the top level, all in one location care that required no effort on their part to access. That ER remains severely overcrowded to this day.

As it stands now, for most places I see enormous obstacles with implementing a plan such as yours here. I do not know this for a fact, but I suspect your society is not nearly as litigious as it is here in the US. Yes, our policies are enacted allegedly for the benefit of the patient, but in many cases, the underlying reasons are actually to prevent liability to the provider, their service, the system, and the medical director.

[Bieber]

Bieber, since when is leaving patients home to die a sign of clinical excellance ? Thats the problem with this generation, you are too concerned about the procedures and treatments you can do to a patient, versus good old fashion assessment. As long as you can do RSI or use a drill to IO someone, you think you have accomplished something. Be a patient advocate first, a paramedic practicum advocate second.

I tend to be rather conservative in my treatments (with the exception of pain management where I always try to make sure my patient is comfortable or as comfortable as they can be). Being a paramedic advocate is the same as being a patient advocate.

Kiwi, can I come work with you?

[HERBIE1]

I tend to be rather conservative in my treatments (with the exception of pain management where I always try to make sure my patient is comfortable or as comfortable as they can be). Being a paramedic advocate is the same as being a patient advocate.

Kiwi, can I come work with you?

I disagree with this, Bieber, but maybe this is simply a case of semantics. The point was, just because you are CAPABLE of providing a treatment/procedure/medication, does not mean that is what is best for your patient. Sometimes less is better- for a multitude of reasons. Starting out as new providers, we want to use every medication in our drug box, and perform every procedure. We want to show everyone how much we learned, and to use our newly acquired skills and find every reason possible to justify doing so. After awhile, we realize that not every person who has basilar rales needs for us to provide a diuretic to "save" them.

Our protocols are supposed to be guidelines, not iron clad rules that are blindly followed without question. Each patient and situation is different, and as long as medical control concurs, deviation from protocols may actually be what is best for your patient. THAT is being a patient advocate.

[crotchitymedic1986]

Beiber, I am a little shocked by your statements, maybe you are playing devil's advocate ? But thank you for reiterrating what I said about your generation, you are more concerned with what YOU CAN DO TO A PATIENT, instead of for the patient.

[NYCEMS9115]

Kiwimedic wrote:

Documentation

If it is not written down: it didn’t occur. Comprehensive

documentation must include:

• Details of patient assessment and findings.

• An assessment of the patient’s competence.

• All treatment and interventions provided.

• What was recommended and the reasons why.

• A summary of what was said to the patient and/or family.

• A summary of what the patient and/or family said.

• Why the patient was not transported.

If the patient is not transported then the patient copy of the PRF

must be given to them.

This is something that they should have done. They didn't do this; that's the issue. Lazy, stupid, jumb, retarded, etc; that's what they are. Most prudent Providers know to do this...

[HERBIE1]

Kiwimedic wrote:

Documentation

If it is not written down: it didn't occur. Comprehensive

documentation must include:

• Details of patient assessment and findings.

• An assessment of the patient's competence.

• All treatment and interventions provided.

• What was recommended and the reasons why.

• A summary of what was said to the patient and/or family.

• A summary of what the patient and/or family said.

• Why the patient was not transported.

If the patient is not transported then the patient copy of the PRF

must be given to them.

This is something that they should have done. They didn't do this; that's the issue. Lazy, stupid, jumb, retarded, etc; that's what they are. Most prudent Providers know to do this...

We do not have the ability to provide a hard copy of a refusal of service to the patient- everything is electronic.

There is a statement the person can read on the computer when they sign their refusal, but it is exceedingly rare that someone even requests to read it- they simply listen to my verbal cautions.

[NYCEMS9115]

So I really don't see why were posting things like; not all patients should be transported, EMS are knowledgeable Providers, patients sometimes don't know when to call 911, we can provide emergent care to the sick or injured, or just because you need to go to the ER it doesn't mean you need an Ambulance.

We're talking about not DOCUMENTING; your verbal recollection is nice but if the written version is not the same or at least similar to the oral one; then it means nothing in the Court of Criminal or Civil Law. That's what's being pondered on.

The 2 cases; the Provider's documentation was lacking or not done at all. Attorneys will have a field day with them. We need to learn from their mistakes; not justifying them...

[NYCEMS9115]

NYCEMS9115: Hey... Where is the PCRs for John Doe, Juan Doe, Jane Doe, Hey Mon Doe, Curry Doe, and Wong Doe?!?

Provider: Oh! They were RMAs...

NYCEMS9115: Okay. Where are the PCRs?!?

Provider: I just finished them. Here...

NYCEMS9115: (Looking at one PCR) Okay, Juan Doe refused, looks okay (Pauses). Where is his signature?!? Who witnessed it?

Provider: (Silence)

NYCEMS9115: HELLO?!?

Provider: Ummmmmm....

NYCEMS9115: Let me see the others!

Provider: Others?...?...? (Looking puzzled)

NYCEMS9115: Yes! OTHERS!!!

Provider: Oh. I didn't get one. Well, you see (Hands moving around) they didn't want to go. Well they didn't need to go. They refused. Ummmm?...? Well, I didn't know; I mean it was busy. I mean I was tired...

NYCEMS9115: Well...... Wong Doe died; family said you told them to call the PMD in the morning... Is that true?

Provider: I didn't say it like that. The guy didn't speak English: so it was hard to decide. The ER didn't have a Chinese

Translator off hours and the Patrol Supervisor was on a 4 Alarm Fire. The patient seemed fine.

NYCEMS9115: WTF! The family is suing; they took him to the ER themselves and the patient died of a MI. Did you even do a 12Lead or V/S?

Provider: Yes, I did vitals but I left the monitor in the truck. You see it was a BLS call. It came over as a sick. The guy didn't c/o chest pain. He was c/o SOB; his lung was clear. He was old so I just thought he just needed rest and see his PMD in the morning.

NYCEMS9115: Did he want to go to the ER?!?

Provider: I told him that since he's talking he's not SOB; his lungs were fine because it was clear. His heart was okay because his vitals were fine.

NYCEMS9115: How about the others: Curry Doe,

Jane Doe, and Hey Mon Doe?

Provider: What about them? They didn't need an Ambulance.

NYCEMS9115: You need to write incident reports on all of them and you need to contact your Union Delegate.

Confucius says, "Lazy Provider who don't document will be in hot water."