Walking Patients to the Ambulance

[J306]

Okay I've read several posts in response to mine, and I'd like to start off by stating that perhaps I should have explained myself more clearly.. I absolutely agree that in which circumstances you decide to use your stretcher depends on your geography and patient status.

However, I'll lay out a call for you I did the other night which has made me have a strong opinion on this particular topic.

At around 0230 on my last night shift, my partner and I were sent to a local nightclub for a

"27 year old female patient, possible overdose".

Now anyone who's been involved in EMS for longer than 15 minutes knows what that dispatch info can possibly mean, anything from a drunk girl who had one sourpuss shot too many, to a party gal who has been drugged and sexually assaulted, driving to the call I had my pre-conceived notions but I kept them to myself like I always do.

We arrived to find a young girl slumped over against the wall outside the bar. The police were on scene as were hundreds of party animals in various stages of alcohol induced debauchery. I walked up to the girl and asked her what was going on, she promptly puked all over her self and then told me she thought she had been drugged.

A quick primary assessment revealed a drunk girl with an slightly altered LOC and no obvious signs of trauma or injury. The girl was literally covered in emesis and her clothes were all askew providing myself and anyone within a quarter mile a view of way too much skin. I asked my partner (first time working with this particular guy) to grab the stretcher and he said something that literally made the hairs on the back of my neck stand up with anger.

"Hey, HEY!! Can you walk? Stand up and walk to our ambulance"

Where do I start?

I have lots of things that drive me nuts in this business, but making patients walk to the ambulance when they are unable to safely do so is right up near the top of my list.

I had a brief little "professional discussion" with my partner about the issue, with him ultimately "pulling rank" and forcing my patient to stand up and stumble to the ambulance.

What happened next? You guessed it, the patient fell to her knees several times, vomited again, and then fell stepping into the ambulance causing herself to become sufficiently wedged between the stretcher mount and the adjacent wall. As I crouched there with my partner, straining and stretching trying to free this drunk pukey woman from her confines, I couldn't help but fume as drunk after drunk after drunk walked by our unit and stared/laughed/heckled.

It was wrong. We looked like idiots and our patients dignity was compromised.

If a patient meets you at their door with a lacerated hand....ok they can probably walk to the unit, but with my aforementioned case, walking the patient is unprofessional, rude and incompetent.

As for EMS being perceived as a low status job...I think that mainly has to do with your attitude, I am all for the "work smarter, not harder" mentality but the fact remains that our job will always have an element of manual procedures which will not be replaced by new technology such as power cots (which add an additional 50-60 pounds to your load)

[mobey]

Oh J306..... I see myself 10years ago

If you had a drunk girl who could stand up on her own, she likely could have walked WITH ASSISTANCE on her own. "Assistance fail"

One person under each arm, and away we go.

Not to get hung up on one case.....

I once too held the parinoia of patients falling, and had it drilled into me "If they call 911, they deserve a stretcher". This is just so untrue.

You need to be more concerned about you're longevity in this profession if you are considering EMS as a career. There are actually very few patients in areas like ours that cannot ambulate themselves to the cot, if the cot is lowered just outside the back of the ambulance, or use the side door for the lower step. You may be changing the words from you're original post, but your tone remains the same.

I like the patient advocacy you are displaying, but remember, you and your partner come before the patient.

You mention professionalism in your post above... here is a thought for you. Carrying patients unnessesarily holds back progression of our profession.

As for power cots, in the hands of non-progressive practitioners who insist on carrying cots around like in the 80's, they are dangerous and should not be used.

I have been using one for 2 years now and have never lifted it. Most practitioners just refuse to change thier traditions. Lemme run a call by you:

Pick up a 65 y/o 250lb with influenza like illness. Coughing, fever, SOB, weak, dehydrated. Single level home.

Walk the pt to the front door with assistance to where the cot is sitting. (or use a stair chair if you like)

Have the patient sit on the cot.

Push the "up button on your 125lb elec cot. Weight lifted = 0

Hook the cot onto ambulance and have your partner grab the handles with you and lift. Weight lifted = 125+250=375. 375/2=187lb. 187lb/2 people lifting=93lb each

Now while your waiting in the hall and the patient has to go pee? Push the down....

Now the cot needs adjusted to unload into hospital bed..... push the buttons.

Seems to me technology, when used properly, is taking away alot of the manual part of our jobs.

[paramedicmike]

I'm with Mobey. That patient could have been walked *with assistance*. There was definitely an assistance fail component to the call. Had you adequately assisted her walk not only would you have helped prevent the patient from falling but you also would have avoided the looking like fools part that you're concerned about.

The upside is that if they were all as drunk as you think they were all those passers-by won't remember a thing.

[Richard B the EMT]

We'll always have the problem of determining the BS from the "Genuine" calls, but someone mentioned having certain patients attempt walking, if only to determine if there's issues, based on their gait (the way they walk). If they move as if they're going to fall down, they get the stretcher or carry chair. If they walk like an Olympian towards the starting blocks of a quarter mile sprint, probably they won't need a carry device (emphasis PROBABLY, although nothing is cast in stone).

As for the person meets you curbside at their building, packed matching luggage set that outweighs the late wrestler Andre the Giant at the ready to be loaded, who tells you they are having a Cardiac Arrest, they will probably need a hospital wheelchair to get them in from the ambulance to the ER

Edited January 28, 2012 by Richard B the EMT

[croaker260]

I also agree that there is a difference between "walking" a patient and letting a patient "walk". Everything is situation dependent, but I have walked the patient you pretty much just described, sometimes forcibly, when the situation (i.e. crowds in the bar, tight confines, "stairs" dictated it. Sometimes even "walked" patients who were barely standing, patients who I would have never walked otherwise in their house, but the "scene dynamics" were such that they were going to be walked out now or I was considering walking out without them.

Once I even walked out a GSW victim with a shoulder wound to the ambulance that was in the staging zone...because the "hot zone" became to "hot" (the shooting was a mini MCI at a party, and the LEO crowd control...didnt control the crowd).

SO Ideal? no. Once size fits all approach? That doesnt work either.

When I was supervising, and I would observe some questionable behavior (like walking patients), I would of course ask the crew about it and base my judgement on their response. If it is derogatory to the patient, poorly worded, or simply "just because its 3 am and Im tired" kind of response, it is a no go. It it was articulate and based on clear reasoning, I accepted it.

SO can you articulate your reasoning to walk the patient on something more than laziness or fatigue? I think the OP did OK articulate his reasoning. Can the opposing poiont articulate his as well? Unless he hops on here we will never know. Chances are its 50% misperception on both sides.

SO I dont think the OP was wrong, but there may be two sides to it..or there may not be. Its a lesson learned regardless.

SO I will close my rambling with a thought of a different vein:

For those services that have policies on not walking the patient, how many of you think its for "safety", or for "billing". We all know, (or you should if your dont) that medicaid and medicare dont pay for may transports where the patient can sit or walk. There are countless examples of (at least non-emergent) calls where "fraud" (yes, the legal term FRAUD with the medicare penalties and jail time) occurred where the patient was walked, but due to service policy (or outright fraud) was documented as being stretcher born.

Thoughts?

Edited January 28, 2012 by croaker260

[Bieber]

Edit: Why were you surprised?

Because I didn't expect you to take such a black and white kind of stance on the issue, to be honest.

Sure. For example in Mongolia I was called to the quarters of a woman that reportedly took an overdose of some drug that I was unfamiliar with and the Dr and Nurse were unable to explain to me. She was obtunded, groaning, when I tapped her eyelid I seemed to get a retarded response, yet she seemed to adjust herself very slightly a couple of times, as if to get more comfortable.

My driver had gotten the cot inside, but I pushed it aside and had him help me lift her a bit, still not really sure if she was bullshitting, partially bullshitting, or if I was missing something. After we got her standing she was allowing most of her weight to hang on our arms, so I kind of grunted and released my pressure, as if I was going to drop her...and she caught herself. Now I knew that she was at least partially bullshitting.

So we left the ambulance at the quarters and I walked her towards the clinic, her clumbsy gait seemed to be fake, so I just talked nicely to her, her eyes mostly closed, her head hanging, yet veered away from the clinic and could feel her kind of nudging me back in the right direction. At that point I was pretty confident that it was at least mostly bullshit.

Was it important that I know how much bullshit was involved? Yeah, in this case a larger clinic with an expat doc in it is several hours away and I have no idea what the drug is and have no way to find out. (it was a small bottle that the doc said came from prescription, but the writing was in Chinese, so no google! God damn it....)

Another time there was an older woman, a frequent flier that was always having a stroke or a heart attack, or was trying to be unresponsive. This time she was kind of confused, but not in any way that I wasn't used to. I was unable to do a stroke scale, as always, but her facial expressions/extremity movement was purposeful/equal/coordinated bilat. If I lifted her hand, she would groan and let it drop...you know the patient...

I could see her peeking at me, as if to see if I was buying the act this time. I had them leave the cot in the other room and told her I had to help her walk...I helped her up, she could always walk without issues, but as soon as her butt left the bed I could feel her fingers dig into my arm causing me to look at her face, which appeared genuinely afraid that she was going to fall. And this was really unusual. I lay her back on the bed and we loaded her up on the cot...I think that it turned out that she'd had some flavor of CVA or other.

So here we had genuine bullshit combined with genuine pathology...And I think that attempting to walk her gave additional information that fed my suspisions. In fact I don't think that she really even knew that she was sick until she tried to stand.

Was it important that I walk her to try and get more information? Not really...I was only about 5 minutes from the hospital, but I friggin' wanted to figure it out on my own. And I do think that trying to unravel every patient, every single one, makes us stronger providers in the long run.

In the end I still didn't predict a CVA, but at least I was able to develop a strong suspicion that I was wrong in my initial assessment, and though that didn't do shit for her, maybe it will do something for the next patient.

Anyway, it's probably not a good way to do it, but it's my way, and I find that gait, facial expression, body movements, anxiety levels, which details a patient pays attention to and whether they seem to make sense in that context or not, when they breathe, when they hold their breath, etc...are often as, or more, telling than a good set, or sets of vitals with many patients.

Dwayne

And now I'm confused because you said you don't like to walk patients, but this post makes it sound like you're more of an advocate of it when appropriate or as a diagnostic tool even in some cases.

Croaker, I liked everything you said up until you mentioned when you were supervising you didn't let crews avoid walking patients if they were tired. Were you ever concerned that their physical fatigue might increase the risk of them dropping a patient while moving them on a cot? And also, did you mean to say that even if the patient was appropriate to walk if their reasoning was that they were tired, you made them use the cot just because their reasoning for walking them wasn't founded in that clinical assessment?

I've never heard of medicare/medicaid refusing to pay us because someone walked a patient, but I'm a long ways down the totem pole... I know I've never been reprimanded for walking anyone, and I always document if I did.

J306, to be honest, I've walked that exact same patient (except she was so drunk she had voided her bowel and bladder on herself), with me and a fireman on either side of her. And yes, I knew beforehand that I would be starting an IV to load her up with fluid and an anti-emetic. If their condition won't be worsened by walking, with or without assistance, and they feel like they're able to walk with or without assistance, I walk them.

[J306]

Oh J306..... I see myself 10years ago

If you had a drunk girl who could stand up on her own, she likely could have walked WITH ASSISTANCE on her own. "Assistance fail"

One person under each arm, and away we go.

Not to get hung up on one case.....

I once too held the parinoia of patients falling, and had it drilled into me "If they call 911, they deserve a stretcher". This is just so untrue.

You need to be more concerned about you're longevity in this profession if you are considering EMS as a career. There are actually very few patients in areas like ours that cannot ambulate themselves to the cot, if the cot is lowered just outside the back of the ambulance, or use the side door for the lower step. You may be changing the words from you're original post, but your tone remains the same.

I like the patient advocacy you are displaying, but remember, you and your partner come before the patient.

You mention professionalism in your post above... here is a thought for you. Carrying patients unnessesarily holds back progression of our profession.

As for power cots, in the hands of non-progressive practitioners who insist on carrying cots around like in the 80's, they are dangerous and should not be used.

I have been using one for 2 years now and have never lifted it. Most practitioners just refuse to change thier traditions. Lemme run a call by you:

Pick up a 65 y/o 250lb with influenza like illness. Coughing, fever, SOB, weak, dehydrated. Single level home.

Walk the pt to the front door with assistance to where the cot is sitting. (or use a stair chair if you like)

Have the patient sit on the cot.

Push the "up button on your 125lb elec cot. Weight lifted = 0

Hook the cot onto ambulance and have your partner grab the handles with you and lift. Weight lifted = 125+250=375. 375/2=187lb. 187lb/2 people lifting=93lb each

Now while your waiting in the hall and the patient has to go pee? Push the down....

Now the cot needs adjusted to unload into hospital bed..... push the buttons.

Seems to me technology, when used properly, is taking away alot of the manual part of our jobs.

I agree with the two person assist; however, not making excuses, but the call and decisions on how the patient would be ambulated to the unit was no longer my decision once the senior staff took it over, made the pt walk and sit on the crew bench which is one of the reasons I find it so frusterating.

If my tone was interpretted as believing that "everyone who phones 911 deserves the stretcher to be brought right to them" well that is simply not true. I believe that every patient deserves to be transported on the stretcher in the position of comfort and should not be discriminated against or carefully chosen who or who doesn't get the stretcher based on personal bias or laziness.

I don't consider any of the patients who I choose to lift "unnessesary" I think it's an intregral part of patient care and is a more proactive approach when done with proper form.

Power cots are useful, but for the place I did my practicum with, it was against policy to lift them into houses because of their extra weight, and in my experience, with the uncx pt's, the majority of the difficult lifting and moving is done in the house and to the stretcher outside.

[paramedicmike]

If my tone was interpretted as believing that "everyone who phones 911 deserves the stretcher to be brought right to them" well that is simply not true. I believe that every patient deserves to be transported on the stretcher in the position of comfort and should not be discriminated against or carefully chosen who or who doesn't get the stretcher based on personal bias or laziness.

I don't consider any of the patients who I choose to lift "unnessesary" I think it's an intregral part of patient care and is a more proactive approach when done with proper form.

I'm curious as to how long you've been in EMS. If you've mentioned it previously I either missed it of have since forgotten.

While I appreciate the position you're taking, you're going to find that you're going to encounter many patients who don't either need or deserve to be transported on the stretcher. This doesn't imply a lack of professionalism on your part. It represents a fact of life and will become a practical part of your life in EMS.

This isn't coming from a disgruntled, back injured old timer. This is from someone who has seen too many back injuries from people who do everything right in terms of lifting yet wind up flat on their back with debilitating back injuries.

[DFIB]

I may be a simple minded dude but if I can get to them with the stretcher I will give them a ride to the ambulance. If they can get on the stretcher by themselves It is taken as a plus.

I do this for several very simple reasons.

First, I began my medical career as a gurneyman at a hospital ( they called us Transport Techs.) The hospital responsibility to the patient extended to the moment they were delivered to a family member and helped to get into their car. I heard people frequently say " I can walk" " I don't need the chair". Despite their protest they all got a courtesy ride to their car.

This experience taught me that if I am responsible for my patient and are going to be their advocate I have to control as many variables of their care as I can. When I place a patient on the stretcher I remove many variables that could possibly cause harm to my patient and ridicule or legal liability to me and my company.

I don't know if this holds up the progression of our profession but it gives my patients the very best service I can provide.

If a patient has already walked himself to the ambulance or has a pretty minor condition I let 'em climb in with assistance.

Edited January 28, 2012 by DFIB

[Vorenus]

I may be a simple minded dude but if I can get to them with the stretcher I will give them a ride to the ambulance. If they can get on the stretcher by themselves It is taken as a plus.

I do this for several very simple reasons.

First, I began my medical career as a gurneyman at a hospital ( they called us Transport Techs.) The hospital responsibility to the patient extended to the moment they were delivered to a family member and helped to get into their car. I heard people frequently say " I can walk" " I don't need the chair". Despite their protest they all got a courtesy ride to their car.

This experience taught me that if I am responsible for my patient and are going to be their advocate I have to control as many variables of their care as I can. When I place a patient on the stretcher I remove many variables that could possibly cause harm to my patient and ridicule or legal liability to me and my company.

I don't know if this holds up the progression of our profession but it gives my patients the very best service I can provide.

If a patient has already walked himself to the ambulance or has a pretty minor condition I let 'em climb in with assistance.

That`s exactly what we were talking about beforehand.

It`s all a matter of ass-covering vs. clinical judgement/valiable need.

Although I see the reasons for those moves and true enough, I have never worked in your region under the condition of everyone suing everybody and anything over ridiculous bullshit - still, you gotta take it as it is: being safe facing legal (reasonable or not) liability. It has nothing to do with "giving them your best service" or best patient-care if you carry them around if they don`t need it.