PSYCH TRANSFER

     EMS Reruns is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we'll pay you $50. E-mail ideas to Nancy.Perry@cygnusb2b.com.

     You've been an EMT for a couple of years now, and you're thinking of going to paramedic school. Your department is a tight little outfit that operates the only ambulances for 30 miles around. That means you run all of the 9-1-1 calls and most of the transfers in and out of your town's 50-bed community hospital.
     Now it's suppertime, and there's a transfer with your name on it. These aren't anybody's favorite calls. A transfer can take a crew out of the district for at least an hour and sometimes two, but it can bring you into contact with some interesting folks. And sometimes running a transfer is simply what people need us to do for them. This one's going from your local hospital to a psych facility in a town about 50 miles north.
     When you show up at the ED, you encounter Everett, a 35-year-old guy in his street clothes, on a gurney, conversing calmly with a nurse. The nurse briefly introduces you and casually hands you the transcript, then disappears. And casual is how things remain as your partner wheels the ambulance down your town's main street and onto the northbound ramp to the highway. You exchange small talk with the patient, but the conversation takes a sinister turn as he tells you he's been thinking "bad thoughts." When you ask what he means, he says he sometimes feels like hurting someone. He looks right at you and becomes this whole other kind of guy.
     You tell him you're sorry to hear he's unhappy, and you secretly wish you had read the transcript. That small voice in the back of your consciousness is getting a mite louder, and you're feeling vulnerable. After a few seconds of inescapable silence, you explain to him that you will need to read the transcript and take some notes, and he seems OK with that. You buckle up on the bench facing him and glance at him above the top edge of the page that says he's a flight risk, he has a history of physical violence, and he's been experiencing suicidal ideations. Thanks a lot, nurse.

     Q. We never really talked much about psych patients in EMT school. How do you deal with a circumstance like this?
     A. We do a pathetic job of teaching our folks about these patients. One of our newest paramedic texts devotes a whopping 20 pages to the subject, and it's not very instructive—especially without a single picture. Twenty pages out of nearly 3,000. EMTs deserve better. Tell you what: This is the kind of patient you never put in an ambulance without reading the transcript first. "Psych" is a medical garbage label, and you deserve to know what it means in each and every instance.

     Q. What if the transcript says the patient has a history of violence or is a flight risk? You can't just go around restraining everybody.
     A. That's what everybody keeps telling us. But if you're going to be alone in the back of an ambulance with somebody whose history says he may bolt on you (or attack you), I say you persuade him to voluntarily accept restraints for his own protection. You can talk that over with the ED physician and explain your concerns. Remind him he has resources that you don't. Chances are, he is not even remotely oriented to the constraints of your environment.

     Q. This sounds bizarre. What about these patients' civil rights?
     A. People's civil rights deserve our respect. But EMTs have civil rights, too. The fact that you're naturally nice enough to help people for a living doesn't mean you don't deserve to come home safe, shift after shift and year after year. Discuss this issue with your medical director before you run even one more of these calls. At the very least, every patient on a medical hold should be restrained during transport. That doesn't have to be uncomfortable or embarrassing for them. The orange Level I wrist restraints we discussed in the February 2007 edition of this journal would suffice, added to the standard shoulder, waist and knee straps you already use to secure every patient to your cot.

     Q. There's really no need to get paranoid here. We transport psych patients all the time without restraints, and we haven't had any problems so far. Why make changes?
     A. People jump out of ambulances and assault EMTs all the time. For obvious reasons, the agencies involved in those incidents don't always publicize them. But plenty of people live right on the edge of their sanity all the time. Throw in a war, an unstable economy and a lack of federal commitment to the poor, and it doesn't take much for them to lose their balance. When they do, they end up in busy EDs that aren't equipped, inclined or paid to deal with them. So, the EDs call us. And when they do, they're often not very informative.

     If you've been lucky, I'm glad for you. Some of us have learned not to trust our luck.

Thom Dick has been involved in EMS for 37 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.