I want to tell you a story about something that happened in the past year. I think that enough time has gone by that I can talk freely about it as long as I leave the names out. This story really drives home the EMS Bubble concept that I have been talking about recently. My jaw hit the floor when this was first reported to me. And I was even more confused by the fact that these events really didn’t affect the outcome of anything. This story, more than any one event, is probably what got me questioning ALS care as a first response and re-evaluating the value of it. It planted the seed that got me thinking about it over the last few months. So here goes…
A short while ago I had occasion to work at a private ambulance company. If you want to search this blog for angry rants about employers it will turn up other things I have written about this period in my life. It was pretty bleak.
Anyway, one of my students worked as an EMT there. I was just wrapping up his paramedic class when I started working there again to recoup some of the money that was flying out the window as a result of my academy failing. We were talking outside one day and he started to spin a story for me. He started to talk about how he took a chest pain in the other day. That’s when I interrupted him.
“Hey, you are making it sound like you rode this chest pain into the hospital. It was your partner, right?”
A lot of people around us starting laughing. I was obviously out of the loop, so I asked what the hell was so funny.
“Haven’t you heard about my partner?”
“Well, yeah. I mean I have seen her. I know who she is. She doesn’t say much, but she seems nice. What’s up?”
More laughter.
“Dude, we switch out every call. And when I say every call, I mean EVERY CALL. We caught a chest pain at a nursing home and it was her turn to drive, so I rode it in.”
More snickering.
“So, let me get this straight. You rode in the back with the patient? And the complaint was chest pain?”
“Yep. And shortness of breath. And diaphoresis. And nausea and vomiting. The whole she-bang man.”
“She knows that you’re just a student, right? She knows you don’t have your numbers?” I was dumbfounded and other people just kept laughing harder. “I mean, I think it would be appropriate for her to let you do some assessments at the bed side. When you guys got to the back of the truck it would be cool for you to be doing 12-leads and making treatment decisions with her guidance. But when it comes time to do ALS procedures and drive, you’re up front, right?”
Now the laughter was out of control. It was obvious that the joke was on me. But a few of them saw I was getting pissed and they assured me that they weren’t laughing at me.
“This is why we are telling you this, man. Welcome to F&B Ambulance! Let me spell it out for you. There was no ALS care. It was my turn, so we loaded the cot in the back and she drove. I put a cannula on her, took a few blood pressures and did the paperwork. We dropped her off at the hospital and went on about our business. Get this, the next call was her turn. It was a BLS patient. She rode it in. It’s fucking luck of the draw man!”
And that’s when it finally sunk in. It was hard for me to fathom just how little this medic cared about what happened on her truck. I kept assuming that this had to make sense or that someone would have stopped it, but all my assumptions were wrong. This had apparently been allowed to continue for months.
“Have you complained about this?”
“Of course I have. I used to make a lot of noise about it. But no one gave a shit and no one around here does chart reviews. As long as we get to bill ALS for so many runs, they could give a shit. So I got crafty for a while. I figured if money was all they gave a shit about, then maybe I should complain that she was making ALS-billable calls into BLS runs and we were losing money over it.”
“Oh yeah, how did that go?”
“They didn’t do anything. I remember talking to the supervisor about it. He looked bored. When I got done he just asked me if there was anything else. I said no and I left. That was three months ago.”
“Well, you aren’t practicing outside your scope are you?”
“Nope. I put a cannula on them and do the paper. She drives. We go to triage and put ‘em in a bed.”
“Okay, what about the facilities,” I was still having a hard time grasping this, “don’t they ask why you haven’t given nitro and aspirin to a patient like that.?”
“Man, that’s the killer thing. The hospitals could care less. They don’t know what our capabilities are. I don’t think they care whether we are EMT’s or paramedics. If they do they don’t act like it. In all the months I have ridden with her I think one nurse has questioned our care, and my medic jumped in with this song and dance about how we were just around the corner and there was no time to do anything.”
“Was that true?”
“Fuck no,” he laughed, “we were all the way across town.”
He relayed another couple of incidents to me. All of them were just as bad. She never checked out the truck. In four months he had seen her open the drug box once and that was because she had a headache. He told me that he had checked into her previous career and found out that she had been fired or demoted at all the places where he asked about her. But at F&B, she had the run of the place. As long as she showed up on time, management loved her.
“So why are you still on the truck?” I asked.
“I can’t give up this schedule, man. I have to go to your class so I can become a medic, get off this truck and do something besides put a cannula on people. Although, I’m starting to think not much more is needed.”
“What do you mean?” I asked.
“Well, everyone gets to the hospital. You name it. Chest pains, strokes, hypoglycemia, abnormal lab values, GI bleeds…whatever. We put ‘em on a cot and drive them to the hospital. I’ve been doing this for four months, and everybody gets there. It’s like chest pains, we take them to the hospital and the nurse probably thinks we are BLS or something. Sometimes the triage nurse will give them aspirin and a shot of nitro while she is looking over the paperwork. So the patient gets it then instead of twelve minutes ago while we were dicking around in the back of the truck at the nursing home. It’s crazy. I have been tolerating this bullshit for months so that I can have the schedule to go to your class and learn how to do what she is blatantly ignoring. But at the end of the call I think I am just charging the patient more and getting no where. I mean, I’m sure we’re living on borrowed time, but nothing has happened yet. I’ll jump out on a limb and say we run at least 4 or 5 ALS calls a day. They all get to the hospital. Nothing bad happens. It fucking hilarious.”
It wasn’t long before I quit. I still know a few people who work there. A few months later I asked about her and I was told that she was still doing it. She just kept chugging along. I was told that the only time it ever became an issue was on ventilator runs. Someone told me that she didn’t know anything about vents and that she had racked up at least “one confirmed kill” but that management hadn’t noticed and neither did the accepting facility. I mean, they obviously noticed that the patient was dead, but no blame was sent her way. The patient was really sick and they figured the arrest had just occurred when they were pushing her into the room. And perhaps it had. I will never really know the details. I can tell you from experience that all the medics there are woefully under trained on the ventilator and most of them have no business running calls like that.
As a matter of fact, when I had just started back working there, they had me go out on one vent run with another experienced medic. When I got back they put me on my regular truck. Two weeks later a certificate showed up in my inbox. It was a certificate for four hours of ventilator training. The medic’s name was on it, and so I went to ask him about it.
“I am tired of this shit man. You remember that run we made together where I showed you the ropes on the vent. They counted that as four hours of classroom training and put it in your file. I have never seen this. I would never sign it. I never had a chance. You were only with me for about an hour anyway.
But this is a whole other can of worms. ALS transports and Community Medic ideas aside, nothing ever happened with initial responses. (I am starting to formulate an opinion that the training for 911 responders should be one thing, and ALS transports and Community Medic should be a complete other set of training that looks much like a degree program. This is way beyond the scope of this post though. In the stratosphere actually.) This medic responded to emergencies for months and it was a complete random chance whether or not the medic or the EMT saw the patient. In that sense it was almost like a randomized study. When the medic did ride in the back, there was still no ALS care given. According to my student she would do an ECG if she felt like it and he had only seen her attempt one IV, which she missed. And miraculously, everyone made it to the hospital unscathed.
Now am I advocating this? Of course not. Is this anecdotal incident conclusive proof of anything? No. But it was fascinating. And just plain dumbfounding. I still have trouble processing this. But it is just one little piece in the puzzle that makes me question whether or not paramedics are needed in the first response setting with their current skills set. And I offer up this wild tale for your consideration and inspection. But please don’t get me wrong, or put words in my mouth. Feel free to be outraged and disgusted. It’s one of the reasons why I don’t work there anymore. Truth be told one day I just had enough, parked the ambulance, and went home in the middle of a shift. I haven’t been back.
But I would like the reader to ponder what would happen if tomorrow you decided to treat all of your patients like this for the next few months. Would the outcome of any medical or trauma patients change? From what I understand, that medic never encountered a respiratory or full arrest at that company in the first response setting. But what if you treated that BLS as well? Instead of a monitor you would use an AED. Instead of intubating you would use a King Airway. Instead of giving drugs you would simply do nothing. Would it change the outcome of any of your patients? And if it would, how many outcomes would be changed?
It’s just a thought. Think of me as the little devil on your shoulder whispering in your ear. Just ignore me and I will go away. Or will I?
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