Earn-A-Ride

Just after midnight on a Saturday night shift, 9-1-1 receives a call from a hysterical young woman who thinks her boyfriend has overdosed. ALS arrives to find a 28-year-old male patient barely breathing after taking 30 mg of Oxycontin along with an undisclosed amount of alcohol. The ALS team assists the patient’s breathing and establishes vascular access, while also contacting dispatch to request a BLS unit to respond to the scene. As soon as the BLS crew arrives the patient is transferred to the back of their rig, at which point the paramedic administers 2.0 mg of Narcan to the patient. The BLS crew is now left with an incredibly angry patient, who just had his $30 buzz blown away with a few pennies worth of Narcan, and the following instructions: “Don’t waste time on the way to the hospital. You’ve only got 15 minutes until the Narcan wears off.” The back doors shut and the BLS teams hustles off down the road with one eye on the speedometer and the other on a wristwatch, while the ALS unit goes back in service and returns to quarters.

Depending on where you work, and the level of prehospital credentials you carry, you might find the case above somewhere between unbelievable and outrageous. That being said, I hear this and very similar cases all the time, as this storyline plays out far more frequently than I would ever think possible. Even more problematic, the frequency of this and similar cases actually seems to be increasing.

Just for the record, in my practice I wouldn’t even entertain the thought of placing this patient in a BLS rig. As I see it, this is unquestionably a true ALS patient, who needs the care that can be best provided by an ALS team.

You’re probably asking yourself how something like this can happen. Let’s take a few minutes to explore some of the possibilities that might lead to such a poor decision, along with the incredible risk that comes with it.

Ignorance—Your first thought might be that the team didn’t know any better. Yet the ALS team clearly knew what they were working, as told to dispatch by the patient’s girlfriend. They also knew to assist the patient’s respirations, as well as the correct drug to give to reverse the effects of the narcotics. They clearly knew the performance characteristics of Narcan as well, since they gave the BLS team the timeframe in which it needed to get to the hospital before the drug wore off and the patient slid back under the effects of the Oxycontin. For the most part I think we can rule ignorance out.

A generational issue—Another possibility is that this is a side effect of a generational issue. This is often represented by the folks I see in my office who early on ask, “What’s the least I have to do to score a sweet municipal fire job where I can work 8 to 10 days a month for great wages and killer benefits?” I do my best to point these folks toward other employment options, where their self-serving, minimalist attitudes are less likely to result in the pain, suffering and possibly even death of another human being.

An overinflated belief in one’s own importance—This philosophy is very evident in those providers who think the real job of an ALS team is to treat only the 5% of patients seen in the field who won’t survive the next few minutes without life saving interventions. The other 95% of the patients we see in the field just don’t seem to measure up and apparently aren’t worth the time and energy it takes to provide competent care.

Laziness—Having looked at the other possibilities which lead down this path of irresponsible medicine, I’ve come to conclusion that the most likely primary cause of this “buff and turf mindset” is simple laziness. I say primary because some elements of the previous possibilities certainly seem to be folded in. Sadly, some ALS providers apparently forget from which they came (a BLS unit), and now just want to work the “really good calls.” If the call doesn’t really measure up to their expectations, i.e. the patient really hasn’t earned a ride in an ALS rig, than they are turfed to a BLS crew.

Irrespective of the combination of errant thought processes which puts these ALS patients into BLS rigs, there are two huge issues. First and foremost is the delivery of sub-standard or possibly even negligent care to patients. Second is the issue of increased exposure to litigation. However, when it’s all said and done, any ALS provider who transfers a patient to a provider with a lesser certification remains liable for the outcome of the patient.

My guess is that it would take an average attorney about 15 minutes in front of a jury to paint the picture of an uncaring, indifferent paramedic, who is in a hurry to get back to quarters to (pick one):

1. Finish detailing their car.

2. Get back to the card game.

3. Continue watching the movie.

4. Get more sleep so they are well rested to go to their part-time job tomorrow.

Once that picture is painted, and the jury sees that a human being has suffered unnecessarily or died because of any of the above listed or similar reasons, all that remains is to get out the checkbook.

As a guy that has done EMS legal work for three decades I can assure you it won’t be a small check.

Until next month …

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of the EMS World editorial advisory board.