crotchitymedic1986

I think you guys are argueing semantics (diagnose versus diagnosis) di⋅ag⋅nose   /ˈdaɪəgˌnoʊs, -ˌnoʊz, ˌdaɪəgˈnoʊs, -ˈnoʊz/ Show Spelled Pronunciation [dahy-uhg-nohs, -nohz, dahy-uhg-nohs, -nohz] Show IPA Pronunciation verb, -nosed, -nos⋅ing. –verb (used with object) 1. to determine the identity of (a disease, illness, etc.) by a medical examination: The doctor diagnosed the illness as influenza. 2. to ascertain the cause or nature of (a disorder, malfunction, problem, etc.) from the symptoms: The mechanic diagnosed the trouble that caused the engine knock. 3. to classify or determine on the basis of scientific examination. –verb (used without object) 4. to make a diagnosis. If a mechanic can diagnose why my car isnt running, I would hope that my paramedic can diagnose why i am having trouble breathing.

So if you responded to a scene where the patient was decapitated, do you have to work that patient ? Obvious death is obvious death, whether it is a cardiac patient that is not responding to ACLS, or it is a trauma patient that has been squished by an 18-wheeler. If you are in a rural setting, I imagine you probably dont have alot of ambulances to spare, so working a dead body for two hours doesnt make sense. Your Medical Director should be able to write a policy that allows you to stop CPR when it is appropriate to do so. You are not pronouncing them dead (thats the coroners job), you are just using your resources wisely.

dwayne, if you were on the call, do you have to call medical control to get permission not to work it, or do you have to start CPR, then call MC to get permission to stop working it ?

You guys need to get your medical control to change your protocols. There is no reason to start CPR on someone that has been down 40 minutes, nor is there a reason to do CPR for 40 minutes, unless it is a cold water drowning. you are wasting time and resources, and putting lives at risk for no reason.

Why couldnt you use a second ambulance crew ?

OK, final comment: Pick any other policy you dont like at your work. Do you enjoy backing a truck in the rain ? No. Have you ever backed into something, probably not. But you have a policy to protect the truck and other people's property, even though you may have the most expert drivers in the world, who have had EVOC, and may not have even had a backing accident in the last year. This policy is the same. Maybe you have only one idiot or lazy medic who would try to talk someone out of going to that distant hospital at 3am in your service. There is no harm done unless you are that lazy medic who has spent 20 minutes talking the patient out of going, and then you hand the phone to your patient, and they tell the supervisor "No, I am not refusing, they told me I dont need to go". The flip side is if it is a true refusal, then you have more evidence that you tried to get them to go, and they did infact refuse. This is simply looking at something that does exist in EMS (like in DC), that is problem prone if not handled correctly. You will rarely get sued by the patients you transport. It is the ones that you do not transport that will get you in trouble. The only reason to be upset by this policy is: a. You are offended by having a supervisor involved in your call. b. You are mad because in this scenario, you will have to transport more patients than you did in the past. If you are doing your job as you should, and your patient is truly refusing, then this is just another layer of protection for you.

No she is not mistaken, apparantly the patient quit breathing sometime in the last few minutes, she still has good color, no rigor, no lividity. P.S. There is no trick, or hidden agenda, it is just a simple question: Would you work this bedridden patient, who if rescusitated will continue this quality of life. I imagine some will because of the full code status, some will not.

Well you are entitled to your opinion. The fact of the matter is, all services have policies to protect the patient, the employees, and the service. Often times, those policies seem insulting to the medics in the field. Your service may have a policy regarding using a backer on the ground, narcotic waste, inventorying the truck, helicopter usage, trauma center usage, or even what kind of uniform you wear and how long your hair can be. All of which, seem stupid to someone in your service. This would be a policy to protect patients, and I have no doubt that many see it as unnecessary, just as I see narcotic waste witnessing as stupid (how does the nurse know you have morphine instead of saline in that syringe) ? I have said all I can say on the subject, you either agree or disagree. I have no further comment.

You respond to your local nursing home for difficulty breathing, and arrive at the scene with 10 minutes of the 911 call. The nurse is at the station completing paperwork, and tells you the patient is in room 19, bed 2. You arrive in the room to find an 86 year old female, who is bedridden, in the fetal position with contractures to arms and legs, Tube feeding running, foley and diaper in place. Pt has a history of multiple CVAs, and is a full-code (god only knows why). She is not breathing, and does not have a pulse. Quick-look on the monitor shows Asystole in all three leads. Nurse comes to room and says "she was breathing when I called 911". Do you work her, or let her cross over ?

Neither lung is working well, lets poke a hole in one of them. You need medication and intubation, needles do not create elasticity.

Paramedic to nurse: Can you please witness me wasting this morphine ? Nurse: I guess, why do you need a witness ? Medic: It's our policy Nurse: Dont they trust you where you work Medic I guess not Nurse: Have you ever abused drugs Medic No Nurse: Have you ever had a drug discrepancy Medic: No Nurse: Are you incompetent or new Medic: Nope, been a medic 20 years For those who are too lazy to read: The supervisor doesnt have to come to the scene, he/she just has to call the patient to verify that it is a refusal. This is a small percentage of calls, it is not every call. And the fact that you know a supervisor will have to get involved, will likely pressure the lazy medic to do the job he is supposed to do and transport the patient. If you dont have a supervisor it could be the senior medic on-duty, but if you are too small to have a supervisor, then your call volume is probably low enough that this doesnt matter. THis type of negligent patient care usually occurs in high-volume urban 911 systems.

Good point, and I agree, but here is the problem with that. Pt signs refusal after being told that they are OK and dont need to go by EMS. Patient signs refusal, pt dies within 24 hours of said refusal. If someone complains, medic holds up said refusal form and says I did everything I could to try to get them to go. How do you discipline that, unless you have a witness for the patient, but even then it becomes patient's family's word against the medic, who has a refusal form ? sorry jpin, typing on a laptop

No doc, they do not need the direct supervision, because all mistakes, nearmisses, and mechanical failures are reported to the FAA. They can then study the mistakes, and make changes to insure that the mistake is minimized in the future, which is why air travel is the safest form of travel. If EMS had to report all events that resulted in a negative patient outcome, to a central body, then we wouldnt need this bandaid. Thanks for the pilot reference DUSt, that helped me alot.

He doesnt have to assess, he just needs to verify that the patient is actually refusing. You have already assessed the patient and determined the need for transport, as you are asking them to sign AMA. The supervisor just asks the patient if they are truly refusing.

I am sorry spin, i didnt understand, could you please rephrase

They also set policy as to what pilots/staff can and can not do; ie.... How many hours they can fly, how much rest they need, when and when the can not consume alcohol, and they mandate that near-misses and/or accidents be reported.

Again you are confusing true AMA refusals where the patient actually does refuse, with refusals that are signed by patients who were talked out of going to the hospital by the EMS crew (like the cases in DC). I am talking about the patients that should go, but are told they will be ok to go by car, or go to their PCP the next day, and then they die.

I do agree with you Dust, but I dont think we can make every EMS worker go back through school, nor do I believe you can mandate a huge training costs to small, rural, employers who are probably barely getting by as it is. If I could wave a magic wand and make every ems worker as competent as you, I would. But that is not feasible.

Ever heard of the FAA -- I think they make those self-sufficient crews do alot of things that they do not or would rather not do. And why does the FAA do that, because when planes crash people die.

My solution doesnt increase the budget by $1.00. You already have supervisors, and as stated they could call the patient via the telephone, they would not have to come to the scene, unless they chose to. We are not talking about every call, just the so called "refusals", which should be a small percentage of your daily call volume. You already have a supervisor(s) on-duty, they would just have to make a few more phone calls during the shift. And this is not referenced to the last several respondents, but could it be that some medics would not want that supervisor oversight, which may make them transport more patients then they normally do ? If you are documenting that a patient is refusing AMA, isnt it prudent to try to do everything to try to get them to go ? But like I said, I am open to suggestion for a practical solution, that can really be implemented.

Good suggestions, and I am not advocating transporting everyone, for the same reasons you sited. Which is why I suggested the supervisor model. If the supervisors were willing to do it, what would be anyone's problem with it then, as it would only help protect you ?

I agree, facts are an important thing, but unfotunately, as stated many times, EMS is not required to report these errors, so the only ones we know about for sure are the ones that resulted in a lawsuit that was publicized in the media. But again, I do not think that anyone of any experience in EMS can claim that mistakes are not made. We can argue about what percentage it is all day, but even if it is only a fraction of 1%, that is still alot of patients, nationwide. Lets just use the busiest service I ever worked for as a Paramedic. They responded to 65,000 calls per year, and had a transport percentage of around 55-60%. If they only had an error in 1/10th of 1% (meaning 99.9% had no errors at all) of all patients seen, that is 65 patients per year (I said errors not deaths). Yes I know that not all calls had a patient, but some calls had more than one patient, so I think it equals out. That is just one county in one state. Out of 65 potential errors, I think it is reasonable to assume a handfull of deaths, when you do not transport 40-45% of patients. And from my experience there, saying 3-4 of these types of episodes sounds about right. But again, if you only saved one life this year, in your area, by changing the way refusals or medication errors are handled, would it not be worth it (by whatever strategy that you use) ?

interesting interpretation, thank you.

Congratulations !!!!!!!!!!!!

please share dust, as I am not at all familiar with their system, only its reputation.