Near-Zero Hero

     EMS Reruns addresses dilemmas in EMS. If you think of an example, send it to us. If we choose to publish your dilemma, we'll pay you $50. E-mail Nancy.Perry@cygnusb2b.com.

     You're working with Ken today. Ken's not your favorite partner because, well, he has a reading problem. He thinks it says "God" on his certificates. Oh, he knows his medicine, all right, and he has way more experience than you. But with Ken, it's always his way or the highway. Besides, he likes to turn ordinary calls into major productions—sometimes doing things to people they don't really need.

     Now it's about 0900, and you're on your way to a private residence where an elderly patient has reportedly fallen. You pull up behind an engine at a neat little one-story home in the middle of your district. You encounter Mary Grillo, a 75-year-old woman lying on her kitchen floor. She was discovered there by a neighbor, and the story is her fall took place three days ago.

     Mary is answering questions and obeying commands. She doesn't know what day it is, but she knows where she is and how she got there. Her complaint is right-sided hip pain, which she localizes with an open hand. You note about two inches of foreshortening and lateral rotation of her right lower extremity. She has good distal color, temp, pulses, sensorium and function on that side, but she guards against any movement of her hip. The remainder of your exam reveals incontinence of urine that smells pretty concentrated, and a three-inch area of soft swelling in the middle of her occipital scalp. You're five minutes from a level IV trauma center, but Ken decides to have the patient flown downtown to a university hospital with a level I.

     Q. See, this is why I don't like working with Ken. A flight will cost this lady $12,500 in our system, and I'm convinced she won't benefit from it. She's stable. We can have her in the local ED within 10 minutes. Now we have to land a helo at a remote landing site, which will require loading, reloading and transporting her in an ambulance anyway. The flight crew won't do anything for her that we can't do, except delay her care and charge her a buttload of money. But I'm a new EMT. Who's going to listen to me? I don't want to be a troublemaker. Still, I feel sorry for this lady, and I feel responsible for her.

     A. It sounds like you're absolutely right to feel that way, unless Ken is seeing something you're not. But the facts you present don't warrant a chopper. Even if he doesn't respond well, it seems reasonable to ask Ken what he's thinking.

     Q. Ken says this lady needs a smooth transport. When I suggest we medicate her for pain and transport to the local facility, he just gives me a thousand-yard stare and proceeds without answering. The lieutenant from the engine company just shrugs his shoulders.

     A. I think it's always reasonable for you to express your observations. This lady's in a position of complete vulnerability; she doesn't know a helicopter from a hot rock. She's trusting you all to act in her best interest, and she has no idea about the costs (which, incidentally, will probably not be covered by her Medicare benefits). Being new in a system shouldn't prevent you from doing what EMTs do every day, namely advocate for people. Then and there, and preferably with the company officer as a witness, advocate. Tell Ken you think it's not right to call in a chopper for this lady.

     Q. Been there, done that. Ken's response is always the same; he punishes you for confronting him by not talking to you for days. Nobody else wants to work with him; it's how I got assigned to him in the first place. What can I do? Ken's behavior doesn't seem right. But as I said, I'm really new at this.

     A. Arrogant paramedics are worth about a dime a dozen (that's dang near zero), and being assigned to work with one is never fun. But don't underestimate your own power, even as a new EMT. If you work for a reasonable agency, they will readily appreciate your concerns—not only about this lady's transport costs, but also about the risks and the added delay of an unnecessary air transport. Besides that, they're very likely aware of Ken's attitude. If you don't work for a reasonable agency, you'll find out real soon.

     That's something you can fix.

     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.