I recently read a story in EMS World about a paramedic who has been placed on administrative leave for failing to treat a patient. According to the article, he arrived on scene, assessed the patient, and despite the requests of the BLS ambulance on scene, he decided to go back in service and triage the call to the BLS unit. The patient was transported to the hospital where they subsequently died.
I am not writing this to debate whether any ALS interventions would or would not have made any difference in the patient’s outcome. There has not been enough information released to even dip one’s toe into that debate. I am also not going to debate the “liability” issue of a lower level of care taking care of a patient when the higher level of care is present because I feel that quite often, if a patient can be triaged, and the BLS unit willingly accepts to take over care of that patient, then there is no issue with doing that. I am writing this to discuss comfort levels.
Throughout my career, I have viewed ALS as serving many different roles in prehospital care. They are there to provide ACLS care, pain management, and trauma care just to name a few, but they are also there to be a safety net for BLS providers who may or may not be comfortable with a patient that is in front of them. With three times the training that a BLS provider receives, sometimes a more knowledgeable presence when caring for a patient rather than a brief pat on the back and a polite “you’ll be fine” is what that lower level provider needs.
In the system that I work in, I often work by myself in a fly car (or interceptor, or QRV depending on where you are from). The majority of the patient contacts that I have are while intercepting with an ambulance staffed by EMTs. Throughout the course of my day, I will see a variety of complaints from stubbed toes to cardiac arrests, depending on what I am sent to. After my assessment is done on my patient, and I am comfortable with what I want to do for them (care for them or triage them off) my attention is turned towards the other providers that I am with. If I decide that I am going to go the hospital with the patient, I start prepping the patient for transport and packaging them how I want them based on what I think I am going to have to do for them.
If I decide that I am not going to the hospital, I have to make sure that the crew that I am intercepting is comfortable with the patient. It is kind of amusing to see someone’s reaction when I ask them, with a straight face, “Do you think you’ll need me or are you comfortable with this?” when the patient sitting in front of us has an extremely minor complaint, but it is not up to me as a higher level provider to judge the comfort level of the person in front of me. It is up to them to decide whether they feel like they can adequately provide for this patient.
There have been times where I have done nothing but sit in the back of the truck and ride to the hospital with a patient without thinking of putting a needle in them or giving them any meds. I did not do it because of a lack of faith in the person who would be taking care of the patient, it was done because they said to me, or gave me some sort of indication that they felt more comfortable with my presence with that patient then they would on their own. After the call, I might talk to the crew about what I thought was going on with the patient, but regardless of whether or not I felt that ALS was needed, I have always and will always remind and encourage the BLS providers that I work with that “if you are not comfortable, call for ALS, regardless of what it is for.”
From everything that I have read about this case in Washington DC, this paramedic not only failed the patient he should have been caring for, but he also failed the BLS crew that felt they needed his assistance. As an ALS provider, we must remember that our commitment goes beyond the patients and extends to the other providers that we work with on a day to day basis. All EMS providers were not created equal. Throughout the field there are a variety of comfort levels and ability levels and we must always keep that in mind.
Always care for your patients, and always remember: you not just a care giver, you’re also someone’s safety net.