Did you like my last post?
If you didn’t read it, which I suggest you do, here it is: You BLS Guys Have Got This, Right?
Good, glad you’re back if you went and read it. However, if you were too busy to do so I’ll recap. In the post I was decrying the practice of BLS providers of questionable competency disregarding responding paramedics in a ludicrously short amount of time after arriving on scene for a patient that sounded like he/she could have benefited from having ALS assessment. It was an inflammatory post, and it was meant to be.
As regular readers of my blog know, I never reveal where exactly it is that I work. While I will say that I work in Northern Illinois and Southern Wisconsin, I never mention the specific service(s) I schlepp patients for by name anywhere publicly. I do this for many reasons, chief among them is my desire to remain employed, but also because I own my own opinions and don’t need nor wish to speak for any specific organization. I have taken a great many jabs at many things over the years I’ve been doing this and I don’t want to single out any specific person or agency publicly with most things.
However if you read any one of my rants or commentaries and believe that I’m speaking to you, feel free to consider what I’ve said and either debate me or change your ways accordingly.
I’m posting this up because I received a comment on my last post that was exactly what I was looking for. It was from a self-identified BLS/ILS provider who didn’t yell at me for demeaning anyone or for being a “paragod” as I called myself in the post, but instead pointed right at the actual heart of the matter.
Boom. She nailed it (She called herself “Trixie” so I’m saying “She”) Provider attitude is everything.
Here’s Trixie’s comment:
“As a BLS/ ILS provider I run into this constantly with the volunteer FD first responders. To be fair, I also have more than my share of medics who turf syncope, seizure, AMS and 10/10 painful fx off to the BLS crew. When pressured to ride it in said medics typically do NOTHING for the patient except take the history and play on their phones in the captain's chair. So I think this is an issue of attitude, not provider level.*smh*”
Trixie, your comment has it all: Distrust of lower-level providers, seemingly valid contempt for higher-level providers, and disdain for people who are complacent and uncaring. Nicely done.
First off, Trixie, if you see ALS providers, or any provider for that matter, “playing on their phones in the captain’s chair” you need to report them to their administration. That is absolutely, unequivocally unacceptable. If you have the ability to switch the organization that provides your BLS service with ALS intercept response to another service that doesn’t have jackasses working for them, I suggest you do so immediately. It is unacceptable for any healthcare provider to be that rude, callous, and uncaring towards any patient at any time.
Moving on, I can see your frustration with the first responders you mentioned. It draws me back to one of my favorite quotes of all time spoken, quite eloquently, by Donald Rumsfeld who you may love or hate as you please. Here’s the quote:
“There are known knowns; there are things we know that we know. There are known unknowns; that is to say, there are things that we now know we don't know. But there are also unknown unknowns – there are things we do not know we don't know.”
I believe that this statement captures the essence of both your and my frustrations with similar incidents. We know what we know, we know what we don’t know, and we know that there are things we don’t know that we don’t know.
We are also certain that there are things the lower level providers in both of our cases don’t know that they don’t know.
In my case, which may or may not have actually happened recently but which I assure you has actually happened in many places many times, I expressed frustration with BLS providers who are looking at the top political priorities of too many EMS agencies, Revenue preservation, Area preservation, Ego preservation, and Political Capital preservation at the expense of patient care. (I’ve written about this problem too in a doozy of a rant which you can find here) In the call in question, the BLS providers cancelled the ALS providers 3 minutes after arriving on scene of a call where a patient had informed the dispatcher that he most probably was experiencing an acute coronary syndrome related chest pain. I decried that this was laughably too short of a time for the BLS providers to have performed any type of assessment at all, let alone one adequate enough to rule out the need for ALS or to Consider PAPPA for Chest Pain. They simply saw that the patient was not dying fast enough nor scaring them enough for them to consider bruising their egos by allowing people with more education to come in and care for him. There was no consideration of the patient’s actual needs nor of providing quality patient care.
Just like in Trixie’s case, my concern is that the providers don’t know what they don’t know. I have no idea whether or not they have any concept of all of the things I would consider for this patient as an ALS provider. It’s not that I’m diminishing their personal mastery of the BLS assessment nor their worth as human beings, but I am responsible for knowing more things than they are and the patient needs to be assessed and probably treated by someone who knows what I’m responsible to know. By their dismissal of this most-probably-needed service for the patient in what can only be assumed to be a blatant display of egoism, they have harmed him. Of course they have, because they are not responsible for knowing all of the treatments this patient may need that they are not able to provide, nor are they most probably able to assess the underlying pathophysiology this patient may have to determine the need for them.
If you think that I’m being disrespectful towards BLS providers you have missed the point.
In Trixie’s case, she is a BLS provider who decries the exact same practice I’m decrying for the exact same reasons when performed by a lower level of care than her own. However in her case, she is also decrying ALS providers who seem lazy and uncaring as well.
Had a paramedic been on scene and cancelled us I would have felt much better about the (possibly fictional) call.
Had a physician been on scene I would have felt a little better about the call, though I would question whether the physician had any idea of the capabilities of the responding ambulances or believed that all ambulances were the same level of care.
Had the BLS providers taken more time before they cancelled the responding unit I would have felt a little better as it would have been suggestive that they had actually performed some type of assessment rather than looking and saying “Not dying now. Cancel the paragods.”
Trixie’s case is no different. However, she then goes on to observe that paramedics “typically do nothing” for the patients she sees them caring for. This is a complaint that I can understand and answer for because I sometimes may be accused of the same thing. The purpose of the ALS intercept is not always to “do” anything that may be visibly out of the scope of practice of lower level providers. This can cause strife. In our area for example, BLS providers are able to obtain 12-lead EKGs but not to interpret them. When we paramedics obtain a 12-lead, read it, and see that it does not indicate for immediate ALS interventions, BLS providers may see this as not doing anything more than they could do if we weren’t in their way. However, we as ALS providers are responsible for knowing what the 12-lead says and for matching what the monitor tells us with physical assessment findings and the patients both long and short term history in a level beyond what BLS providers are responsible to know. You could be an EMT that lives each day to read www.EMS12lead.com and devours Dr. Smith’s ECG blog but as an EMT you may have that knowledge but aren’t responsible for knowing nor acting upon it so you cannot be counted on to have it and must defer to people who are held responsible for knowing it, whether they do or not. The paramedic may be trusted to have weighed the pros and cons of providing the ALS level interventions. The BLS provider cannot be. The patient deserves to have the higher level knowledge making the decisions for them just as they also deserve to have a physician ultimately evaluate and provide care for them once they reach the hospital. This is not ego, it is a well-established heirarchy.
Another problem that Trixie pointed out is that ALS providers sometimes do not do what the BLS provider thinks they should, and in the case of a disinterested ALS provider checking facebook from the captain’s chair, this may be the case. If you’re a BLS provider and you observe an ALS provider not providing adequate treatment for their patient, such as appropriate pain control or other interventions, feel free to speak up. Ask them first, and you may be surprised at their answer such as not being able to give narcotic pain control to a patient with hypotension, or withholding nitroglycerine in an inferior MI. However you also may get a flippant answer, which if you do requires you to inform the appropriate parties for proper investigation and action.
Patient care comes first, y’all.
I personally know Trixie’s frustration with this. A while ago I had a patient who did not have outward physiological signs of a STEMI but had a 12-lead EKG that our machine interpretation flagged as *** ACUTE MI SUSPECTED ***. I read that EKG myself as I always do, and could see what Dr. Lifepack happened to be getting at although it was subtle. Even though I had a low index of suspicion, the patient had underlying chronic conditions that confounded their assessment and I could not rule out a STEMI. I had to activate the cath-lab and bypass the closest ED with the patient for definitive care with suspicion that the patient didn’t really need it.
When I got to the hospital I was met by an angry nurse who chastised me for calling the STEMI alert. She was dismissive of me, my patient, and my assessment skills. She ignored the 12-lead and hadn’t done her part to activate the hospital’s STEMI response as I had requested. In fact, she made the statement “You shouldn’t have bypassed <community ED> with the patient. If He/she was having something real that’s what <name of flight service> is for.”
I was incensed and imagine that this could be the feeling that keeps BLS providers from calling for ALS intercepts when needed. I do not wish to be this kind of provider and if I am or have been in the past, I throw my apology out there to the ether.
The fact is, we all operate under a hierarchy. We all have people who we answer to and who may answer to us. Life is like that and it’s not always pretty. However, when faced by the sheer importance of patient care and our unwavering responsibility to our patients and to those we serve, our respective egos must be removed from the fight.
Trixie is right that there are some jerks out there wearing paramedic patches that may inappropriately downgrade patients to BLS out of laziness or the nebulous condition known as “burn out.” To those providers, I say that it is easier to seek other employment before you get fired for killing someone than it is to try and find a job afterwards.
To the BLS providers that are afraid of having their egos bruised further and don’t call for ALS when it’s indicated, I say exactly the same thing.
It’s clear that we need better communication throughout the entire spectrum of care and the medical hierarchy. We also need to all be better leaders, be more tactful and compassionate, and to obtain more education because there is always something more to learn. Those unknown-unknowns are things that can kill someone some day and it is one of our highest responsibilities to prevent that from happening.
Remember, it’s not about you, it’s about others. Be nice, be professional, and know your stuff.
Let's stop the war.
For more on this topic, from both sides, read these: “Who Needs them paragods?” or “Paramedic Honored for Inaction in Local Ceremony.” In addition, for more information on the ALS intercept, read “Paramedic Intercepts and Rural EMS.”