Inflicting Care

      You're in a field at the scene of a crash next to a state highway in your service area, with a mouthy 20-year-old kid who rolled his older-model pickup at high speed. He's a little confused, and he's not very nice. You can't help noticing an odor like alcohol on his breath.

   He has a mangled left lower extremity, and his leg and ankle are entrapped in the floor pan. The engine company manages to free him and then lands a chopper, whose crew decides to transport him to a trauma center about 30 miles away. He's lost a unit of blood or so, but his bleeding is controlled. He saves a few insults for the chopper crew, just to be fair. Together you select a vacuum splint to stabilize his injury as found, secure a couple of lines and move him toward the helicopter. But before loading, the flight nurse elects to paralyze him and intubate.

   The patient seems stable, and you really want to question the need for RSI. But you don't get to choose your air services, and this one requires its personnel to log their frequencies of certain procedures annually. If they don't perform some procedures often enough in the field, they have to do so in the hospital on their days off. So they perform them in the field…one way or another. (They brag about that, actually.) And the patient doesn't know it yet, but the unnecessary procedure and a 10-minute transport will cost him $12,000.

   Q. This particular flight service routinely performs unnecessary skills on uninformed patients to compensate for their lack of high-acuity calls. I hate it, and I wish I could do something about it.

   A. Actually, you can do a lot about it. Why do you fly people in the first place? Would a 30-minute ground transport have made a difference for this guy? Choppers don't just arrive on your scenes by magic. While it's your scene, you're the one who can best assess the mechanism of injury, the patient's condition, the weather, the traffic, the visibility, the risks and therefore the most beneficial mode of transport. If the patient is lucid enough, you can also explain the options to him before that helicopter ever arrives—including the cost of a flight. Let's face it, he's going to be stuck with the consequences. And an unexpected $12,000 bill for someone who won't be able to work for months can be simply unsustainable. Considering the financial times we all live in, he could end up living on the street.

   Q. I'm just a small-town paramedic. The flight crews have access to retrospective information, like clinical status on arrival, x-rays and most important, outcomes with time. It's pretty hard to argue with those sorts of things.

   A. Maybe, but you don't have to. The size of your town has nothing to do with the quality of your decisions. You're responsible for field findings, field instincts and field decisions—not in-hospital ones. You're certainly not accountable for retrospective findings. If you're a paramedic, be a good paramedic and be true to the public. You may be questioned occasionally, but time and again that's the gold standard your colleagues will use to judge your performance.

   Q. I feel responsible for keeping our ambulance in district. We're not Miami-Dade or L.A. County, and taking an ambulance out of district for two hours is a big deal to us.

   A. That's a sentiment lots of people have, no matter how big their systems. You should take it seriously. But when you have a patient, the needs of that patient outweigh the potential needs of people who may need you. Take care of the emergencies you have the best you can, and leave the rest of the system to others.

   Q. What about those unnecessary procedures? They worry me a lot. We're talking about a flight service with a $20 million-dollar budget. How can one paramedic impact the practices of an agency with that kind of power?

   A. One paramedic who consistently advocates for the helpless has a lot of power. Be nice, but do act. Talk to the flight crew directly. If their answers don't make sense, share your concerns with your medical director. Talk to the trauma coordinator at the receiving facility. And finally, submit the case for review. What could happen? You could learn something. Your system's protocols could change, and its medicine could get better. But make no mistake. You know that face you saw in your mirror this morning?

   It's going to be there again tomorrow, and the next day. And the day after that.

   Thom Dick has been involved in EMS for 39 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS Magazine's editorial advisory board. Reach him at boxcar_414@yahoo.com.