Just after midnight, 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 mg of Narcan. 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 team 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 about things like this all the time. Even more problematic, the frequency of cases like this 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 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 time frame 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 ask early on, “What’s the least I have to do to score a sweet municipal fire job where I can work 8–10 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 lifesaving interventions. The other 95% of the patients we see 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 leading down this path of irresponsible medicine, I’ve concluded that the most likely primary cause of this “buff and turf” mind-set 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 measure up to their expectations, i.e. the patient really hasn’t earned a ride in an ALS rig, then they are turfed to a BLS crew.