Patient Advocate

[DwayneEMTP]

...You cant have it both ways, either it is unsafe to transport this patient all the time, or is it just when you deem that it is unsafe to get you out of doing a transport. What other type of patients do you refuse to transport ? The poor, minorities, drunks ?Here is something you might want to read:http://www.uwhealth.org/emergency-room/obesity-bias-weighs-heavily-for-ems/20377

Easily gets my vote for the most idiotic thing said on the City so far this month.

Fyre, she's not going to be able to understand the whole concept of cost/benefit. She's made that clear I think. Which leads me to believe, and I'm truly not meaning this as an insult, that the 'manager' in her description is for a paid per call volly service.

Girl, the fact that you're unable to grasp the fact that a paramedic is responsible for all who enter their care, and all of the results of anything that follows makes me wonder what, exactly, you really do for a living. I'm smelling bullshit here, I'm just not sure exactly what flavor it might be.

If this is an emergent patient, then you operate on one set of priorities, non emergent, another. Anyone in this field should know that. And to imply that this decision is being made based on discrimination against fat people certainly speaks more to your mentality than it does to the scenario presented. And to suggest that loading her onto the floor of an ambulance in an unsafe manner like a wounded cow instead of insisting that she, like non bariatric patients, is provided a safe means of transfer is just transparent hypocrisy.

If all goes well, as it seems that it has in the past, then there are no issues other than your inability to make sound, patient focused decisions. If it doesn't go well, say, with even a minor fender bender, then every ailment real or imagined just became the responsibility of the medic that accepted this patient and chose to transport in an unsafe manner. And if it is more than a fender bender and there are real patient deficits due to the medics decision to transport in this fashion then it is well past time that you stop considering yourself a true patient focused provider and simply admit to be the whacker that you've proved to be.

It may be time for you to get out of the office for a while and back on the street where real world, difficult decisions have to be made.

And JP, to suggest that this patient should be transported despite a providers misgivings simply because some other asshole is willing to do it is the very weakest and impotent possible logic for a prehospital provider. I'm not assigning those labels to you, as I know differently from your previous post, but to this line of logic only.

MG, if you had been dismissed over this incident you should have used that as a sign that it's past time to move on to a more professional service. A hardcore medic friend of mine once said, after I'd been fired from a service for what I considered to be aggressive, but strong medicine, that he'd never met a good medic that hadn't been fired. Though I've not found this to be the end all barometer for medical providers I've certainly seen the truth in it over the years.

There is no question whether or not a bariatric rig could have been provided for this lady. I've worked some really remote places and it's always an option, though it means giving the transport to another, non local company. The fact that these services were willing to risk harming her instead of bringing it in shows that they are more concerned with snatching calls than customer care.

I think that you did good MG...And for what it's worth, I'd be your partner any time.

Dwayne

[BushyFromOz]

I am sorry, but I would have terminated you.

First of all, the stretcher bar and antlers are easily removed from the floor. We do this type of transport frequently, we typically roll them to the truck on the hospital bed (fully raised), remove the head board and then just slide the mattress and patient into the back of the truck, then reverse the process at the receiving facility.

Id sack your ass for removing safety devices from the vehicle and endangering the patient, your partner yourself and the wider public with your stupidity

You probably pissed off every social worker and nurse in that facility, and showed them exactly how valuable your competitor is. There are very few services that have a bariatric wench and lift for an ambulance, so the other ambulance may not have been any better equiped than you. It is not your job to determine who you will and will not transport.

Wrong knackers, part of transporting is doing it in a way that does not endager the patient.

Hopefully you will still have a job when you go back to work, but do not be surprised if you do not.

Hopefully they dont ever let you into a managerial position

P.S. You have no idea what the next stage of treatment was, so you may well have delayed definitive care. She may have been scheduled for a procedure of some sort that day or the next day.

If thats the case the onus is on them to provide that transport and if the sending facility doesn't have its shit together than tough love for them

Possibly the most idiotic thing ive read in a while.

-5 for being a tool.

[nypamedic43]

I guess I would be terminated immediately then. I would absolutely refuse to transport this patient, on a mattress, on the floor with no safety equipment. The risks FAR outweigh the benefits. If I get fired for putting the patient's and my safety first, then so be it. And just because this has been done before doesnt make it right....it only makes you very very lucky that nothing bad has happened and to be honest, you are tempting fate if it continues.

How does be sued help anyone? Because you know that if something bad happens, the patients family will be over the lawsuit like white on rice. Can you afford to be charged? lose your cert? your job? go to jail? lose everything you own? I think not. Medicaid only pays $126 for a non emergent transport plus mileage. Is it really worth it considering what you would lose in the event of an accident? Not to me it isnt. And if I was the medic that you wanted to take this transport hatelilpeepees...you would have been told, in no uncertain terms, what you could do with your job, especially if you, in your management position, had told me, take it or be fired.

[DFIB]

That's assuming that another company is present that has the appropriate resources. According to the OP, the normal transfer company does the mattress on the floor routine. So what to do if the only difference between the regular service and your service is the name on the side of the ambulance, and not the tools inside it?

I think the difference is that it is the other guys cert. on the line if he makes an unsafe desision. He/she can be responsible for their choices. I can only say what I would do and what I am willing to risk or not risk. I would rather risk my job than my certificate or my reputation.

Edited October 8, 2011 by DFIB

[JPINFV]

And JP, to suggest that this patient should be transported despite a providers misgivings simply because some other asshole is willing to do it is the very weakest and impotent possible logic for a prehospital provider. I'm not assigning those labels to you, as I know differently from your previous post, but to this line of logic only.

That's assuming that the misgivings of the provider are properly founded. Personally, I'll argue that this isn't necessarily a straight forward case. Similarly, I'm not impressed with the unsaid underlying tone of, "Well, sucks to be the hospital, you're now stuck with the over weight patient."

To suggest that providers misgivings shouldn't be critically examined gives credence to every post by an EMT who refuses to transport a patient 4 minutes down the road to the ED because the patient is "critical" and that they should wait 8 minutes for the local paramedic service to arrive. After all, it shouldn't matter that other providers are more comfortable delivering a patient to the ED based on ETA, just that those providers aren't comfortable.

Oh, and do you transport babies in their mothers arms or do you only transport babies in car seats unless a time sensitive emergency is present?

There is no question whether or not a bariatric rig could have been provided for this lady. I've worked some really remote places and it's always an option, though it means giving the transport to another, non local company. The fact that these services were willing to risk harming her instead of bringing it in shows that they are more concerned with snatching calls than customer care.

If bariatric rigs are readily available, then how come they weren't apparently commonly used? If bariatric rigs are readily available everyplace, how come 911 services are being given a pass? Not every 911 bariatric transport is going to be a time sensitive emergency, but they're being given a pass simply because it's 911, and the assumptions being made about the severity of all 911 calls.

[usalsfyre]

That's assuming that the misgivings of the provider are properly founded. Personally, I'll argue that this isn't necessarily a straight forward case.

Rarely are situations such as this.

Similarly, I'm not impressed with the unsaid underlying tone of, "Well, sucks to be the hospital, you're now stuck with the over weight patient."

Frankly, I'm surprised the hospital agreed to allow the transfer to go forward, considering they arranged the transfer with a service they knew didn't have the proper equipment it's likely they could be included in any subsequent liability claims. I've had hospitals refuse to allow transfers in a standard cot before, despite the patient only weighing 400lbs for this reason. I'd be willing to bet their legal and risk management departments are blissfully unaware of how these patients are moved.

To suggest that providers misgivings shouldn't be critically examined gives credence to every post by an EMT who refuses to transport a patient 4 minutes down the road to the ED because the patient is "critical" and that they should wait 8 minutes for the local paramedic service to arrive. After all, it shouldn't matter that other providers are more comfortable delivering a patient to the ED based on ETA, just that those providers aren't comfortable.

Different setting and you know it. You've even commented non-emergent IFT and EMS should be separate.

Oh, and do you transport babies in their mothers arms or do you only transport babies in car seats unless a time sensitive emergency is present?

I haven't put a kid in their mother's arms in years. What makes an ambulance different than any other vehicle on the road?

If bariatric rigs are readily available, then how come they weren't apparently commonly used?

How often is furosemide administered routinely by EMS and community EDs for CHF without considering the situation? Just because it is so doesn't make it right.

If bariatric rigs are readily available everyplace, how come 911 services are being given a pass? Not every 911 bariatric transport is going to be a time sensitive emergency, but they're being given a pass simply because it's 911, and the assumptions being made about the severity of all 911 calls.

I've waited on scene for bari resources on 911 calls. 911 services should not get a pass, and I expect it's an issue that will become more visible as time goes on. This is also a place where community paramedicine of physician availability would truly excel as some issues could be handled without transport.

[DFIB]

We have touched on various approaches to the transport of morbidly obese patients. I would like to pitch a couple of different ideas into the mix.

I was considering the discrimination angle as far as obese patients are concerned. Most morbidly obese patients know how much they weigh and how difficult it is to be transported. I mean everything about their health is specialty oriented.

I am tossing around the idea that the real discrimination is cramming them in a unit not appropriate for their size. Kind of like a hospital with no wheelchair access.

How would they view a provider that crams them in a unit that is too small? Expeditious or uncaring?

Are they embarrassed when they are crammed into a unit that is not appropriate for their size? Could a patient successfully sue for being transported in a unit that is to small?

Wouldn't they already know that transport requires specialty units as well?

I wonder how the morbidly obese patient views a provider that would recommend a bariatric rig because of unsafe conditions in a standard ambulance? Would they take it as a sign of caring, laziness or something else?

Do they appreciate the time and care demonstrated by the provision of equipment rated for the task or resent they need a specialty unit for transport?

What happens if they develop a cardiac or respiratory emergency condition in route and there is no room in the truck to work them? Or get nausea from the ride?

[DwayneEMTP]

Ok...abridged answer.

Of course decisions should be critically evaluated. But that's not what HLPPs was doing. She was stating that she should be fired based on this call. It sounds like she saw it as straight forward.

Risk/benefit. Google it. Man, do whatever is necessary. But please don't make any more critical decisions until it's well understood.

There are a million ways that this call could have been, but what we have available to discuss is the scenario presented here.

I once was reprimanded because the local hospital was trying to empty out because of an upcoming blizzard. They wanted me to take a 80+ year old active MI on a 90 minute transport to a cath lab along with a 280lb prisoner from the local nursing home, who was under police supervision, to the same city, to be transferred to a physch hospital.

Their argument was that he was well medicated and hadn't been an 'issue' in several days and was considered 'low risk for violence.' I met him, he seemed sweet as pie, and I refused him. I was not going to be distracted by a second patient while trying to care for a patient that was likely going to die before the end of the transfer anyway. If he was good, it was a bad situation, if he was bad it was a catastrophic situation. See, being a paramedic and all, I believe that I am morally and ethically obligated to make such decisions.

I transferred my elderly patient on the 4 hr turn around, then came back, loaded him up and did the same thing again. It made for a long night in snowy conditions, but it was the responsible thing to do.

My bosses were pissed because it "would probably have been fine. We've done it many times before." But they weren't responsible for my patients well being, I was. Fuck the legal ramifications if you want, and the argument remains the same.

And I can't claim to have not hauled children on their mother's laps. There have been times when I had relatively hypoxic children that I couldn't keep a mask on and would fight me when I attempted blowby that I felt needed other care that I couldn't provide if they were strapped into our inflatable seat. So I had the mother hold them, provide the O2, and I did my work. I felt that the benefits outweighed the risks...

See...there's that pesky phrase again...

Dwayne

[zmedic]

Yeah. At the end of the day it is the responsibility of the person doing the transport to decide if they feel comfortable with the transfer. Whether it is an EMT being asked to do a transfer that is clearly ALS, a medic being asked to titrate a medication they don't feel comfortable with, or a situation like this.

I personally think I would have called the supervisor back and had them come to the scene, show them the size of the ambulance etc. If they still want to do the transfer let them take responsibility for the call. I'll drive their truck and they can sit in the back.

[medicgirl05]

I personally think I would have called the supervisor back and had them come to the scene, show them the size of the ambulance etc. If they still want to do the transfer let them take responsibility for the call. I'll drive their truck and they can sit in the back.

This company isn't like a typical private service. It is run by a family and my "boss" dispatches calls to us while doing her normal everyday things. I did measure and the patient width and the clearance of the truck and report that back to her.

Well, I am scheduled to work there tomorrow so we shall see if I still have a job when I show up in the morning. Thanks for all the input!