New Doctor

Newguy and I are taking an older gentleman into the hospital having an active stroke. It’s a legit stroke: all of a sudden he couldn’t move his left arm or leg, and his face started drooping, then his slurred speech started.

“Hot stroke” as we call it.

I’m giving my report to the nurses, and apologizing for sticking the guy 5 times without getting an IV.

Literally, all I did on the way to the hospital was 1) call a report on the radio, and 2) make this guy a pincushion.

I’m in the midst of a bad IV streak. I was 2-for-9 that day.

Some new doctor I’ve never seen before walks into the room. Most physicians in this emergency room wear scrubs, and occasionally a white coat, but this guy looks like a Brooks Brothers catalog cover model. Pressed khakis, cordovan wing tips, light blue pinpoint oxford, and a regimental rep tie.

He listens to the rest of my report while he walks over to the patient.

As I’m finishing up my report and grabbing a signature from the nurse, he looks at me.

“So y’all didn’t get a line?”

“No. I tried a bunch, but I didn’t get one. Sorry.”

“That’s cool, don’t worry about it” he says as he turns to the nurse. “Let’s go ahead and get him over to CT, and call Neurology.”

He takes his stethoscope off and begins listening to breath sounds, and turns back to me.

“Did y’all get a sugar on this guy?”
“Yeah, it was one-forty-four.”

“Good. We need to know the sugar. That’s some important shit.”

“Fixed it”

Slimm and I are taking some poor lady to the local rehab hospital. This poor hapless soul made the mistake of slipping on ice, and banging her head on the pavement. Now she has a tracheostomy and needs a ventilator.

Unlucky for her, she is now here.

We make our way to the room after the obligatory signing in of the patient at the front desk. Which makes no sense to me, but I’m just an ambulance driver transporter paramedic, and not a policy maker.

We hear the alarm before we make it to the room.

Slimm makes it to the door first and I can hear his eyes roll from the other end of the cot.

Inside the room is an obviously exasperated respiratory therapist, fumbling with the hospital ventilator. Obviously, something is not like it should be.

“I can’t get it to work! Something is wrong!” she says very excitedly. “I’ve never heard it do this before!”

Slimm catches my eye, and his eyes glance at the wheels of the hospital bed, and back up to mine, and I get it. Three years of silent communication are good for a partnership.

Meanwhile, the RT has reached the end of her wits. She looks like she is about to quit.

She pulls out her phone and punches the numbers violently. “SOMETHING IS WRONG WITH THE VENT IN FOUR EIGHTEEN AND I NEED ANOTHER ONE AND THERE IS A PATIENT HERE ON A VENT WITH AN AMBULANCE AND I DON’T KNOW WHAT IS WRONG WITH THIS VENT AND I KEEP HITTING ‘SILENCE’ BUT IT WON’T GO OFF AND SOMETHING IS WRONG.” she says, to someone who might have more experience in these matters.

She turns to us: “I’m going to have to go get the vent from across the hall” she says as she walks out.

Slimm’s face doesn’t move, and his eyes don’t turn. His right foot makes an almost imperceptible movement to the foot of the bed, and activates the bed’s lock.

The alarm stops. Like we both knew it would.

Our patient continues to be unconscious and unresponsive on our cot.

The respiratory therapist reappears at the door, less exasperated and more perplexed.

“What happened?” she asks.

“I fixed it.” Slimm replies. “It’s cool now.”

 

Sometimes we should refuse transfers

Almost once a month, I see in my Facebook feed a link to the article from several years ago in which a Florida ambulance service was ordered to pay a 10 million dollar settlement to the mother of a baby that was born in the back of one of the service’s ambulances. The mother was being transferred from one hospital to another, due to the patient’s (apparently) precipitous labor. The mother’s water broke, and the baby was delivered (and heroically resuscitated) in the back of the ambulance. Unfortunately, the baby suffers from cerebral palsy, and a jury in Florida found that the ambulance service was liable for the injuries to the baby, because they did not have the appropriate equipment on board.

I trust that the story is easy to find, and has been read by the majority of us already, so I won’t link to it here.

I’ve argued that the service never should have taken that transfer in the first place, and that the service is most certainly liable.

Most of the Facebook comments on these threads follow a common pattern; that: 1) the paramedic performed a heroic thing by resuscitating a 25-week fetus, 2) the ambulance crew should have called their supervisor or medical direction prior to taking the call, 3) shock that an ambulance service would be held liable when they saved a very difficult patient, 4) the plaintiff must be money-hungry, and 5) the ambulance service should have demanded that a hospital employee ride in the back of the ambulance with the patient.

I will never argue with anyone on the first point. I know several people who work for EVAC, though not this particular paramedic. I can only imagine the difficulty this paramedic encountered when faced with having to resuscitate a pulseless, apneic 25-week fetus with only the help of their EMT partner. This was very strong work by an EMS crew, with a much better outcome than would have occurred in a lot of other situations.

I don’t agree with calling a supervisor or medical direction. Calling a supervisor for guidance would be only minimally helpful, and a medical director phone call does nothing to remove liability from the providers. This ambulance service was most certainly liable, from the actions of the call-taker to the paramedic who accepted the transfer.

All too often, if the paramedic had refused to take this patient (as some would), they would be viewed as a “problem” employee who was “refusing to run a call.”

To address point number four, I don’t believe the mother of the baby is “money-hungry” in the least, but that she is now faced with paying for a lifetime of care for a baby who suffered injury at the hands of the ambulance service.

And to address the final point, asking for a rider from the hospital only provides the paramedic with another pair of hands. Hospitals (in my experience) are hesitant to send riders for several reasons. First, because they lose the nurse for several hours, and staffing levels are affected negatively. Second, many nurses are not protected from liability when they leave the hospital grounds. Nurses operate under a physician while in the hospital, much like paramedics operate under a physician while in the ambulance, which begs the question; which physician does a nurse riding along operate under?

Several years ago, I was called in the middle of the night to a small, rural hospital to transfer a patient to a very large hospital that was more capable of taking care of him. The patient was incredibly sick, with a PaCO2 in the 90s, with a PaO2 in the 70s. This patient was on BiPAP, and the sending hospital was absolutely bouncing off the walls to get him out of their hospital. While I was working on a critical care truck, my ventilator at the time did not have the capability to provide BiPAP. I informed the sending physician that I wasn’t able to transfer this patient in this condition, and he was apoplectic. The sending hospital was not in the position to send their BiPAP machine with me in the back of my ambulance, as it was the only one they had, and they couldn’t be without it for the 5 hour round trip.

While the physician was incredibly mad at me, I stood my ground, and he finally asked what needed to be done to have the patient transferred, and we discussed the case. The patient was sedated, paralyzed, intubated, then placed on my ventilator for the transport, which was uneventful.

When I got back to the station in the morning, my supervisor called me into the manager’s office to discuss the call. The phone call they received from the sending physician led them to believe that I did not want to run the call, and that I was rude, and incapable of handling a patient on BiPAP. After explaining the potential liability that the company would face had I transported that patient as he was, everyone agreed that I did the right thing.

I was fully prepared to walk out of that hospital that morning without a patient. I act in the patient’s best interest first, as we all should, but I also keep in mind the company’s position. Those two don’t have to be in contrast to each other. If we act for the company first, by taking the call because it is a paying patient, then that is not always in the patient’s best interest. If we do the right thing for the patient, then the company will, more often than not, be okay.

“Yeah, but…”

I’m doing an ACLS check-off for a group of physicians as part of their biannual renewal. It is some of the easiest work I have ever done, and I have a blast doing it.

I give the delightful gastroenterologist his scenario, a middle-aged male who is waking up from his lower GI study. He doesn’t feel good, and it is only going to get worse from here.

Doctor Endoscopy asks for a set of vitals, and learns the patient is hypotensive, bradycardic, with pale, diaphoretic skin, and very weak.

“Okay, I want to put him on the cardiac monitor.”

“Sure thing. That’s what you get when you turn on the monitor” I say, as I press the button on the rhythm generator that hints it will display something resembling a a complete heart block.

“That is a third-degree heart block. I need someone to start an IV, and put the pacing pads on him.”

“Okay, your secretary has started an IV, and the janitor has applied the pacing pads.”

“Okay, I want to give point-five milligrams of atropine.”

“Are you sure?”

“Yes.”

I pause the scenario, as best as a scenario can be paused. “Um, atropine isn’t going to work in a complete heart block.”

“Well, I’m the doctor, and that’s what I want to give.”

“Yeah, but…”

Borracho

“This is Jose’. He had a little bit too much to drink and he fell-”

“How do you know he had too much to drink?”

“Have you been in the room? I can still smell him from here. Anyways, he tripped over the carp-”

“Did he tell you that he had too much to drink?”

“He isn’t here because he is drunk. He’s here because of the big gash on his-”

“So he isn’t drunk, and you are just judging him because he is Mexican?”

“Actually, he is from Guatemala, but when he tripped, he fell forward and-”

“Where do you want me to sign?”

“Right here,” I point to the appropriate spot.

“Good. You can go now” comes the reply, as she walks into the room. “Good morning, sir. What happened?”

“I got drunk then tripped over some loose carpet in my house.”

I can’t resist. I stick my head behind the curtain.

“Told ya so.”

Things I said today

“I really like this crown molding. Do you think I could get your carpenter’s name and number later? Now, which hospital do you want to go to?”

“She really doesn’t have room to call anyone racist. There’s a framed picture of Huey Newton hanging on her wall.”

“I don’t know what it is. Call it atrial bigeminy. That should confuse them long enough.”

“No sir, I don’t want to see your testicles. I believe you.”

“I’m sorry you are having a bad day. Perhaps you shouldn’t have come to work?”

“Dude, we just hiked half a mile in 90 degree heat to get to you; you’re going to the hospital.”

 

It was a busy day.

Irony

Your hospital doesn’t ever answer your med radio. Like, ever. You say that I am supposed to call in by telephone, but the number you want me to call gives me voice prompts that tell me to do several things:

  • “If this is a medical emergency, hang up and call 911.” Lady, I AM 911. The emergency already happened.
  • “Press two for English. Oprima siete para Espanol.” I’ve been in this field since the Clinton Administration, and I have yet to find the need to call a report in anything other than English. I have used Spanish, German, French, and even Sign Language to communicate on the scene of a call, but have yet to meet a nurse that doesn’t have a rudimentary understanding of the English language.
  • “Press one for billing inquiries. Press two for radiology scheduling…” Seriously. The chances this bill is getting paid in the first place is slim-to-none, and I sure ain’t the one that’s gonna pay it. And I sure as heck don’t have time to be paying attention to your voice prompts.

Further complicating the matter here are three more things: First, I do not carry my cell phone with me on scene. It stays in the ambulance. My friends and family know what I do for a living, and they know how to get in touch with me without calling or texting. Any communication I do can wait until I am done taking care of my patient. Second, my company does not issue me a cellphone to carry with me. They do issue me a radio, and there is one in the ambulance. The same one that I try calling you on. Lastly; my employer requires me to call reports to a hospital on a recorded line. Interestingly enough, the 800mHz radio channels are recorded while my phone is not.

So I don’t call on the phone. But you know that. And you get mad every single time I show up with a patient who would probably do well to sit in triage until shift change. And every single time, I tell you the three points above. I don’t have a phone in the back. The company does not issue me a phone. My company policy is that all reports have to be recorded.

We should agree to just stop this rigamarole. For real. It gets tiring.

So when I show up all like “Surprise! A paramedic brought a sick person to your emergency room!” you get all mad and hussy and make me wait half an hour before you come into the room to take report. You aren’t fooling anyone. We all know the ER is more than half-empty, because we saw the lack of people in beds when we walked in. We know you aren’t busy, because we heard the conversation you were having with your coworkers. We heard all about those recipes you found on Pinterest, what your friend said about your boyfriend’s best friend’s girlfriend on Facebook. We heard about your new favorite TV show, New Girl.

We heard it all because your nurse’s station is literally behind the room you assigned this patient to.

But it’s okay. This guy is kinda cool. We chatted about his golf game while you thought you were upsetting me by making me wait. If you hadn’t been an uppity bitch, he wouldn’t have invited me to play golf with him.

In Augusta.

At freaking Augusta National. For free.

So, thank you. I appreciate your disdain for me. I enjoyed your punishment.

A comment from Flash Larry on “Who is the customer / You make the call”

So Flash Larry blew up my blog, again, with one of his comments. Really though, I appreciate your comments, Flash. Ladies and gentlemen, I have a notion that Flash is more knowledgeable than most of us could hope to be.

My previous post questioned what the correct action would be when an EMS unit is told by a healthcare provider and a company policy to transport a patient to a certain hospital, and what the consequences of transporting that patient to a hospital that is not equipped to handle the specific problem. In this instance, interventional cardiology.

I have pieced together Flash’s reply, and added my comments as well.

He begins:

 The issue here is one of informed consent. In my state, a patient has the absolute right to be transported to the facility of his choice with one exception.

 This is always a good topic, the one of “informed consent.” What exactly is “informed consent?” Are we to inform each patient each time we establish an IV that there is the risk of catheter shear, which could cause an embolism? Are we to inform the patient, or family member, each time we administer dextrose that there is the risk of infiltration, which could cause tissue necrosis and the possibility of loss of the affected limb? I think that might be going a little too far.

I do not think informing the patient of their current medical problem and the care that is necessary is going too far. We get into that in just a little bit. Stand by.

 The exception, which bears discussion: The regulations state that if the EMS service medical director has established a “reasonable distance” for transports that the medical director can override the patient’s wishes if the patient wants to go further than the “reasonable distance.” The intent of the regulation was to prevent a patient from demanding transport to a distant city. It is my understanding that the medical directors of some services are establishing “reasonable distances” that insure that patients go to particular hospitals of their choice. The matter has not yet been litigated but at some point, it will be and then a jury will determine what constitutes a reasonable distance. That will be interesting both in the courtroom and in the newspapers.

 Flash answered my question before I had time to ask it: Just how far is a “reasonable distance?”

My company has a policy that states, in essence, we will transport a patient to any hospital in a county that is contiguous with ours. And that seems reasonable. In the previous scenario, Roundthecorner Medical Center and St. Elsewhere are in two contiguous counties.

I once worked in a city in which ambulance service was provided by two privately owned hospitals. The hospitals and EMS services got along very well, because they had the patient’s best interest in mind. While I worked for both services at the same time, it was routine to transport patients to the hospital of their choice, regardless of what was on the side of my ambulance. “Which hospital would you like to go to?” became a staple question during my assessments.

 I don’t know what the laws are in your states but here it appears that the ambulance service rule is denying the patient the right to informed consent, which is actionable at law in several ways. As all of you know, patient consent is required before you treat them. Under the law of my state, if a mentally functioning patient is informed as to what you’re doing and doesn’t express opposition, then consent is presumed (this arose out of a patient who did not expressly consent but did not object to care and then turned around and sued for failure to obtain consent. The appellate courts ruled that the plaintiff should have expressed opposition at the time of care rather than suing later).

 Frankly, I do not know the specific laws in my state, but I will be a good little blogger and go research them.

When the word “actionable” is used, I have to ask “actionable against whom?” As far as I can tell, it is my duty to provide the informed consent, and I am responsible if my actions violate the law, regardless of company policy. If my company policy requires that I physically touch each and every patient, yet I physically touch a patient who has refused my touching, then I have commited battery, and no company policy is going to provide me coverage in a court of law.

A far-fetched scenario, I know.

However, the second part of consent is that it must be informed. The patient must be informed of his condition and risks of treatment. Therefore any rule that states otherwise is contrary to law.

Therefore, this patient should be informed that his EKG shows what may be an imminently serious cardiac condition that is usually effectively treated by a particular procedure, be told what the different facilities can and cannot do, what your recommendation is and what you’d do with another patient in the same condition for whom you had not received specific orders. It is not necessary to tell him that they screwed up the 12-lead but that yours shows something different than what they got when they took it and things might have changed (they do, actually).

The patient is then able to make his own informed choice as to where he should go.

It’s not necessary to suggest, then or later, that the transferring facility made any errors. The most important thing is that your documentation supports your decision.

 The hospital in question, Roundthecorner Medical Center, can perform cardiac catheterization, but cannot perform interventional cardiology. Most often what happens when they perform a catheterization in which a stent is needed, is that the hospital will place an intra-aortic balloon pump, then have the patient transferred to a hospital that is capable of PCI.

While it is not necessarily my purview, I can’t help but wonder if RMC informs those patients “Hey, we couldn’t fix this problem when you came in the door, and we knew that, but we decided to ‘take a look’ anyway. Now we have to put this complicated piece of equipment in your aorta to help your heart pump, wait on a receiving facility to actually accept you, and wait on an equipped, knowledgeable ambulance crew to come transfer you. Sorry we didn’t send you there sooner.”

Whenever I am handed paperwork from any healthcare facility, I look at it, and make not of what they found. I always perform my own tests because, as you say, things change. Things change frequently and often.

 If you do not proceed in terms of informed consent, you and your company (under the doctrine of respondeat superior) could be held liable at law for any injury to the patient caused by taking him somewhere he didn’t want to do or by not informing him of his conditions and the destination options. As well, the paramedic could be in danger of losing his license for violating state regulations. I assure you, if it comes to a court case or administrative hearing, the ambulance service will NOT send in their owners and managers to say, “It’s not his fault, we told him to do that.” They will say, “We never, ever, ever would tell one of our employees to do anything that would be detrimental to patient care or in violation of the law.”

 For those that are interested or don’t know, respondeat superior is Latin for “let the master answer.” In many cases, the employer has to answer for the actions of their employees. It is also known as the “Master-Servant Rule.” Essentially, the employee cannot be held liable for actions that he performs when those actions are required by his employer. Actions that are outside the scope of the law, however, do not make the employee immune to prosecution for those actions.

If, however, the employer says, as Flash alluded, “We never, ever, ever would tell one of our employees to do anything that would be detrimental to patient care or in violation of the law.” and the employer can prove with company documentation that the opposite is true, the employee’s actions could still be actionable.

Ignorance of the law is not a defense.

 Which brings me to a question, CCC? Is that policy that you specified actually in writing anywhere, or is it word of mouth? (see above paragraph if it’s word of mouth or less than explicit)

 This policy is explicit. While not in an employee handbook, it is in writing elsewhere.

 If, on the other hand, you transport the patient to the appropriate facility (18 miles away) WITH the patient’s informed consent, and most especially if you are proven right and the company takes an adverse personnel action against you, the company may be liable at law in a lawsuit brought by the employee for creating a policy that violates state law. I can also assure you that public opinion would not be on the side of the company either, if it became public. Nor, I think, would the patient support the company’s adverse personnel action. Nor, I think, would the transferring office (who must have some reason for wanting them transported to a particular facility) be interested in having it made public.

 Employment law in my state allows an employer to terminate an employee for virtually anything. That isn’t to say that the employer would not be liable for creating a policy that violates state law, however.

I believe the public should know what we are doing, and why we are doing it. But that’s just me.

 Always, always, always do that which is in the best interests of the patient and what complies with the law.

 I have always done what is in the best interest of the patient. While I did not take the Hippocratic oath when I began working on an ambulance, I believe whole heartedly to “do no harm” is the ultimate goal. “Doing harm” can be something as simple as transporting a STEMI patient to a hospital that does not perform PCI, at least in my eyes.

 One of my more famous moments was when I was dispatching one day (yes, I did that too) and with all my units tied up, had a walk-in to the station having a possible heart attack. After warning my units to hold their traffic, I put the patient on high-flow oxygen, went back in and called a competing private service to come get the patient out of our main station. It was the only option I had. It was in the best interest of the patient. Fortunately my boss at the time ever only asked one question when you went outside the box, and that was exactly that. Was it in the best interests of the patient? As he said, every time, “Patient care comes first.”

That’s the way it should be.

I am glad your former boss saw the patient’s well-being as the first and foremost responsibility. Even though we compete with each other, the ultimate goal is the same: take care of people.

Patient care always comes first.

Thanks for your comments, Flash.

Who is the customer/You make the call

So; a scenario:

You respond to a local urgent care center where a Nurse Practitioner (there is no physician on staff) shows you to a middle-aged male who came in complaining of chest pain. The NP informs you that she performed a 12-lead, but didn’t see anything “really too wrong.” She also informs you that she has already called report to Roundthecorner Medical Center, and they are awaiting your arrival.

Roundthecorner Medical Center is one mile away.

After loading the patient in your ambulance, you perform your own 12-lead and almost fall over when you notice the humongous ST-segment depressions in the anterior, lateral, and septal leads.

Roundthecorner Medical Center does not perform interventional catheterization. They can perform caths, but can’t place stents. (Don’t get me started on that one.)

St. Elsewhere is 18 miles away, and they have the whole host of cardiology services.

For the sake of argument, your patient is stable enough to make the trip to St. Elsewhere. I’m not too interested in treatments, just the next decision to be made.

Your company policy says you must transport the patient to the hospital that the customer (in this case the NP) selected, and you are not supposed to even attempt to persuade the patient to choose another hospital.

Do you:

A: Take the patient to Roundthecorner Medical Center

B: Inform the patient that he is having “the big one” and transport him to Roundthecorner Medical Center

C: Inform the patient that he is having “the big one” and suggest he goes to St. Elsewhere

D: Suggest to the patient that he go to St. Elsewhere as opposed to Roundthecorner Medical Center, without telling him why.

 

I’m interested in reading your choice, and why you made that choice.

I’ve always held that the patient is the true customer, and the one we should be most focused on. I’ll let you all know what I would choose some time in the next few days.

Not really a stabbing

The “stabbing” that we sent 12 people to, blaring their sirens and flashing their lights, turns out to be a goofball who poked himself in the top of the hand with a steak knife.

Some college-aged moron was playing the “knife game” while drunk.

I have seen the future, and we are doomed.

Nevertheless, he actually bled a good amount. One of his roommates was kind enough to bandage everything up before the fire department got there, and he did a darned good job of it, too. Like, 4×4 dressing and kling wrapped, and tied in a knot.

The bleeding is controlled, and not a single spot show through the bandage.

I think the roommate said something about being a boy scout, but he was slurring his words pretty hard. Regardless, I’m not one to remove a bandage just to look at a wound, when the bleeding is already controlled.

Laziness, maybe. Maybe not.

He wants to go to the hospital across the county to be near his mommy. If I were drunk and stabbed myself while playing the knife game on a dare, the last place I would want to be is near my mother. It’s a low-priority call, so Slimm jumps in the back and I drive.

I catch about 20 minutes of a Rush Limbaugh rerun on the way.

At the hospital, after dropping him off, my Slimm is approached by the doctor on staff.

Hey, did you guys even look at the cut on his hand?”

No, not really. The bleeding was controlled by the time we got there, and the bandage was already on. We didn’t want to remove the bandage just to look at it.”

I’m hiding around the corner, but within earshot, working on my first cup of coffee.

Well, you guys should have looked at it. It’s only like, two centimeters long and not very deep. It will probably only take one stitch, but we might be able to glue it.”

Oh, so you guys can handle it? Or do we need to run him down to the trauma center?”

I choked on that sip of coffee.