Standards of Care
At sometime in every EMT's career, he or she finds themselves occupied in a call that involves a family member. Whether it is your family or a family member of the EMS community, there is a special type of stress and/or caution associated with that particular kind of call. In show business, it involves a thing called "flop sweat." EMT's know it as an adrenaline rush. None of us wants to fail, but somehow it is as if the eyes of all our brothers and sisters are watching. There is a special place in ambulance hell reserved for those who fail our "own" in their time of need.
Hypothetically, based on an actual call, a family member living in New York City has a Vasovagal Episode while in the bathroom, loses consciousness, hits his head and injures his arm. This is a common occurrence, as we all know well.
When the EMT basic crew arrives, they take a history of present illness, assess the patient, and then diagnose the injured party as having Vasovagal Syncope and proceed to walk the family member to the ambulance and sit him on the bench seat. Although he appears to be A & O times three, he does complain of dizziness and disorientation.
What's wrong with this picture? Anybody in his or her first week of EMT school have an answer?
Know Your Role
Firstly, in New York City and many other systems, EMTs do not diagnose, paramedics do. Secondly, why weren't paramedics called to the scene because the patient was obviously altered mentally? Thirdly, with a loss of consciousness and trauma why wasn't the patient put on a board and collar? Should I go on or am I just beating a dead horse?
Actually, new research on the general use of a board and collar suggests it can do more harm than good. However, until research proves the new findings and/or we can have a portable x-ray on the ambulance, we have to proceed with what has worked in the past.
As EMTs I suppose we could make ourselves annoying and call EMS command and report or question the incident. At the very least find out whom the EMTs were and have a little chitchat with them. However, we were not on the call and did not know how it really played out. We also can hypothesize what the possible responses would be: "Why didn't he tell us that he was related to a member of EMS?" or "He signed a release form!"
Weren't we all taught to treat every patient as if they are a family member? Again, I am just guessing.
The aforementioned relative, young and healthy, told all of us Monday Morning Quarterbacks that while he sat on the bench seat, he was asked/coerced into signing "something" saying that he did not want a board and collar; his signature was obviously obtained after walking to the ambulance.
Patients with "Altered Mental Status" should not be signing anything in the first place. Next, since the mechanism of injury warrants a board and collar, the EMTs should have known better and as we learned: ignore the patient's wishes in some cases. So what was the big problem on this and so many calls?
We as pre-hospital providers get annoyed at our co-workers, our partners, and our patients. All patients lie, right? Moreover, not just EMTs make the wrong choices. Paramedics, doctors and nurses are just as guilty and careless.
In New York City, as a paramedic, my partner and I went to many calls that turned out to be Basic Life Support. In almost all cases, we treated and/or transported the patient. In the system where I now work, both EMTs and Paramedics go to the same call. If it turns out to be a Basic emergency, the patient is triaged down, the paramedics return to standby status, and the basic unit treats and/or transports the patients.
The problems of dual response are many. EMTs get into the habit of not wanting to "bother" the paramedics and paramedics get "bothered" if the dispatchers call them too often. Rather than deal with "personalities" the EMT basics might cancel the advanced units. This type of attitude can be a recipe for disaster. The successful outcome of a patient is for the basic unit and the advanced unit to trust one another. This sacred trust only comes from the two levels of care working with each other on a regular basis and knowing each other's strengths and weaknesses. This mutual trust happens mostly in a perfect world, but it does happen.
Don't Forget the Basics
The solution is when paramedics arrive on a scene that patient contact was initiated by EMTs, the basic unit must make the advanced unit do their job. If the paramedic wants to release the patient to EMTs, it is the duty of EMTs to ask why. Forget all that nonsense about covering your behinds and liability issues, egos, and drama. We put on the uniform to help people who are sick and dying, so let's all get over ourselves.
There may be a very good reason why the paramedics do not think that the patient needs advanced care and the decision to release or triage down needs verbalization and understanding. A paramedic stating, "this patient doesn't need medics" or "this is a BLS call" is not good enough.
On the other hand, if a paramedic unit arrives and finds a patient, such as my family member or your family member or a homeless person, not in a board and collar, the first question should be, "why is this person not boarded and collared?" If the answer is "this person refused treatment" the response should be, "what was the mechanism of injury," as you open the side compartment of your ambulance and pull out that long orange thing.
If the EMT basic does not do his job properly, it is the responsibility of the paramedic to correct that error, not say, "that EMT really doesn't know what he is doing" post call. In addition, you might find yourself working in a primitive system, (hypothetically speaking of course) where all paramedics are "paragods." Every medic in that particular system is a "great" medic and EMTs are groveling at their feet, just low enough that they could be kicked when they were down. Medics do not know everything and neither do doctors. Sacrilege! Sacrilege! Sacrilege! Burn paramedic Rella at the stake!
I happen to have been very fortunate and worked in systems in which there was a mutual trust and respect between medics and EMT basics. Rarely have I run into crews that want to "be released" from the scene when my partner and I arrived. If they did, they were taken along for the ride to the hospital and here is my reasoning: If you call me, that means you need help. Your patient just became our patient. BLS before ALS and I am just continuing the care that you initiated. BLS does not stop, just because we are administering advanced care.
The bottom line is, in most cases, paramedics cannot do their job without the support of EMT basics and sometimes EMT basics cannot do their job alone.
Finally, treat every patient as if he is my family member; treat every patient as if that person is your brother, sister, parent or child. Anything less is not meeting the standard of pre-hospital care.
Stay safe and please feel free to direct any questions or comments to my website at www.francisrella.com or info@francisrella.com.
Francis Rella worked as a teacher on the high school and college level for 13 years before changing to a career as a paramedic and registered nurse.
He has served in the Armed Forces with the United States Marines, the US Navy Reserve and the 11th Special Forces Group (Green Berets).
As a member of Actor's Equity, AGMA, AFTRA and Screen Actors Guild, he has worked as an actor for PBS, National Public Radio, New York City Opera and stage companies in New York and throughout the United States.
His first book, "Manhattan Medics," (Princeton Book Publishers, 2003) has received outstanding reviews and he has also received national awards for his Screenplay and television scripts. He has just completed his first novel entitled "Lullaby of Broadway."
Francis grew up in Brooklyn, New York and attended Cathedral Preparatory Seminary, where his studied for the Roman Catholic Priesthood. He went on to study at St. Vladimir's Orthodox Theological Seminary after college for the Priesthood.
He holds a Master's Degree in Music, a Nursing Degree, and is pursing a second Master's Degree as an Acute/Critical Care Nurse Practitioner at Seton Hall University.
In addition to writing projects, he continues to work as a paramedic, emergency room and mobile intensive care nurse in New York City and New Jersey. He is also a Special Law Enforcement Officer in his hometown of Old Bridge, New Jersey.
