HERBIE1

Prehospital, the sign that CPR is being properly performed is indeed a palpable pulse- if you feel a femoral pulse, then clearly you are doing effective CPR. Oxygenation-o2 sats, ETCO2, color improvement, EKG changes to a viable or shockable rhythm vs an agonal rhythm, pupils constricting(before Atropine administration), etc- all indicate how things are going. As for checking the femoral pulse, in a prehospital setting, some things are also easier said than done, based on the scene, the patient's size, are you in a moving rig, the level of training and experience of the person monitoring that pulse, etc. I've had first responders and EMTB's tell me they feel a return of a pulse when a person is clearly in a confirmed asystole. If the patient "looks" better, then clearly you are doing things correctly. All the gadgets in the world are great but I think you also need to correlate them with the clinical picture. If we cannot get a ROSC, then our job is to keep the patient as viable as possible until the ER can pick up care and possibly provide an intervention or medication that we cannot. Obviously with CPR, ensuring proper compression rate and depth is useless unless the patient is being adequately oxygenated, so I guess the more ways you have to measure a patient's condition, the better idea you have of how effective your efforts are and what, if any adjustments need to be made.

Maybe this is an issue of proprietary terms and local vernacular, but one thing that keeps sticking in my head is "rapid trauma assessment". What was this patient's presentation that deemed such an assessment necessary? Doc alluded to it-was it the blood? Copious amounts of blood from the scalp- or anywhere for that matter- can be distracting, but you need to look past that. Like Doc said, a scalp bleed could look horrible but is actually not necessarily clinically significant. Think of a heavily bleeding but nontraumatic epistaxis in a normotensive and otherwise healthy patient- the scene and the patient can look like a horror movie, but people don't generally bleed out from their nose, and any ER could handle such an issue. To me, when someone needs a rapid assessment- medical or trauma, that means they are unstable in some way- airway issues, multiple obvious and potentially life threatening injuries like a GSW to the chest or back, CSF or grey matter visible, etc. Then you do your ABC's and see what level of care the patient would need. It appears that in this case, the mechanism of injury was known, so it was not a fall from a height, struck by a car, or other high speed impact, so a thorough evaluation of the patient's condition AND their complaints is not only warranted, but mandatory. The index of suspicion for an internal injury would not be high(except for a potential closed head injury) from a fall from a standing position. Take your time to do a thorough exam- especially if it means deciding how and where the patient will be transported, whether to mobilize an ALS unit, or a chopper evac. Let the patient's condition dictate the proper route to take. As for the age of the crew chief- that would scare the hell out of me too.

Need more info. Vitals, mentation, anything on physical exam- even a cursory one. But... A simple quick exam may have revealed a hip fracture- shortening, rotation, etc. Maybe not. The fractured skull may or may not have presented with obvious signs or symptoms. Assuming vitals were stable, a fall from a standing position may or may not exhibit obvious injuries, but with an elderly patient, obviously you need a higher index of suspicion. I don't know what your local protocols are, but in this area, unless you had reason to suspect such injuries, it may not warrant a trauma center. It would depend highly on the capabilities of the local ER, distances to a trauma center, etc. I once had a 60 year old guy who fractured C-2 with a small 1inch forehead lac as the only obvious injury when he tripped and fell backwards while walking, so anything's possible.

True, except I almost delivered one of my daughters- in the hospital birthing room of all places. Sudden onset of an urge to push, of course the OB doc had already left because it would be "awhile", and turns out she never left the parking lot before she was called back. I hit the call button and said we're having a baby. My wife had one hand, squeezing for all she was worth, and I notice my daughter is already crowning. Of course the staff was running around like idiots, dropping the equipment from the ceiling, grabbing trays, gowning and gloving, and I fully expect that my little girl was going to squirt out onto the floor. I have one hand guiding the head, and finally a resident's eyes get really big, realizing he was not ready. Just then our OB walks in, I tell her she can take over since a one handed delivery is probably not the best idea, so she laughs, grabs a pair of gloves, and calmly squats down to deliver my little girl. I was pretty disappointed I didn't finish it- of the hundred or so deliveries I've participated in, this would have been the first tax-payer. LOL

One comment: To your point number one- it's only insurance fraud if you document that this person is nonambulatory when they can actually walk. Besdies, maybe the person is unsteady, can only stand for a moment, or trips and falls? Now you have some explaining to do as to why you made a patient ambulate when it was not safe to do so.

Don't they need to be FF 2 trained for this?

That;s going to be a tough one to prove, other than with anecdotal evidence or inferences. Example: Regarding the IAFF's nonsupport of the Scope of Practice issue. That's not condemning education, but clearly that's what the end result is if you oppose something like that. I would be very surprised if you can find anything "on the record" where a fire department organization would ever say something that decries education for EMS or fire. That would be an enormously bone headed move. Personally, I think this issue varies greatly depending on where you live and work. Some areas are very progressive, while others are traditional(old school). It also depends on the age of the respondents to such a question, as well as the stance/attitude/actions taken by the leadership of the person's organization.

Congrats to you, mom, and baby! I hope her little fingers are ready- they need to be able to support daddy when he is wrapped completely around them! (which generally occurs about the time the placenta is delivered, or at least it did in my case...) LMAO @ Richard. Too funny...

To me, this isn't about American health care, it's about being certain your final wishes are respected. Very specific advanced directives should have prevented this poor woman from being shuffled in and out of hospitals. If she was in hospice, then chemo, radiation, and multiple other tests and treatments should not have happened. I feel for the patient and the family, but they had options, as we all know, like medical power of attorney. Shame on the doctors for not explaining this to the family.

You will need to ensure that you are practicing under an MD's license. Obviously if you work for a private provider, those things will be taken care of. Remember, we cannot function without a doctor's license.

Agreed, Richard, but I think the original issue was that everyone on scene was the same level of provider, so highest medical authority wouldn't matter.

LMAO Funny stuff, but I do hope this wasn't a city ambulance that was taken out of service for this stunt.

In our area, the FD has been called on to do everything from pot hole patrol- (cruising the streets of their district and reporting bad streets), and even water newly planted trees and flowers in parks during a drought. Funny, EMS units have never been asked to do such things. ( Maybe it's because they are too busy doing their jobs???)

LMAO Not bad...

In the middle of a cardiac arrest, on my Blackberry. (I love to multi-task)

Here's a wrinkle nobody has brought up. Again- I commend Dwayne on his decision, but... To answer his question about the ethical/moral dilemma of treating enroute, what about a trauma patient? We have had the "golden hour" concept drilled into our heads with the intent that the less time spent onscene, the better the outcome for the patient. Anything you can do enroute, you do. Obviously a seriously injured trauma patient will not be "fixed" by anyone but a surgeon and an OR. My point is, time, place, and APPROPRIATE care. In the case of a trauma patient, definitive care is NOT with us, but a simple hypoglycemic diabetic with no complicating factors really only needs to have their glucose level increased. In this case, the man needed more care, but it was more of a social service intervention than a medical one. If you could ensure that he would get the needed resources and agencies involved with his care without transporting him, then he would be getting his "definitive" care. Problem is, we all know how slowly the wheels of government agencies turn, and there are no guarantees that help would get there in time for him. All this shows to me is that as EMS providers, often times we need to think outside the box. We improvise, adapt, and try to do what's best for the patients but many times these situations are not written in an SOP or policy book. THAT to me is what makes this job fun- problem solving and playing detective. Nearly anyone can master the skills and procedures we perform, but not everyone can adapt those skills or hunt for a "better" solution to a problem.

Cool- Thanks, Dwayne. We need to work on this in our area. Our department is more concerned about getting billing information than making our jobs easier.

Well done, Dwayne. I've done the same thing myself, for similar reasons. Clearly this is a social service as well as a medical issue, so better to get him to a place that has the resources that can at least attempt to address those needs then to release him back to the same situation, where he might not be so lucky the next time. Immoral? Hardly. It was the most decent thing you could have done for this person. We are not supposed to be automatons out there- we need to make judgment calls and this one was spot on. The easy solution would have been to juice him up and get another refusal. That does him no good- and essentially ensures you will be back again in another day or 2, and the next time you might be too late.

"But many doctors you call on the med radio or ER will not force you to transport to the ER because they are worried about liability of forcing or "kidnapping" a patient." I have never encountered a doctor who was truly worried about that. In my experience, docs are far more concerned that an unsuspected injury or illness goes untreated by allowing someone to refuse transport. On the other hand... As long as you paint an accurate picture of a fully competent and oriented patient who is aware of possible consequences to their refusal in your radio report, I have rarely encountered resistance to allow a refusal. When I first started in EMS, I worked on the streets and in ER's. We used to have a blood alcohol lottery and try to guess the levels of inebriated patients. Everyone who came into the ER who appeared to be intoxicated had serial blood alcohol levels drawn on them and only when they dropped below the legal limit, they would be discharged. These days, especially with regular drunks who everyone knows well, many times no levels are drawn because these people appear to be stone cold sober with levels that would put most of us into comas and can actually experience DT's with levels around 200. The reason they are in an ER- they can no longer walk and are a danger to themselves, not simply because they are intoxicated. These people are actually drunk basically 24/7, but sometimes they simply over do it and end up in the system. Once they sleep it off, become functional and stable again, they are discharged. Wrong- maybe, but in a busy urban ER, you could tie up every ER bed waiting for someone's levels to drop to below the legal limit and have no room for MI's or CVA's.

Does the patient receive a hard copy of these instructions, or is it something you simply recite to them? I think we all know what to ask, what to say, and instruct patients as to what to do, but if patients truly do not retain this info, then what good is it? Again- does the patient actually receive a copy of these instructions?

Interesting stat about people not remembering the instructions given to them about follow up care. I wonder if that is unique to a hypoglycemic episode. I suspect that in many cases, people remember little of what a doctor/EMS person/RN tells them regarding their follow up instructions, care, options and responsibilities- especially if it is not specifically written down for them. For many people, medical information causes their heads to spin and they tune out. I know hospitals give discharge instructions to patients that are specific to their particular problem, so I wonder if handing out a similar form for prehospital refusals would be a good idea. Does anyone do this? We have patients sign an electronic form that lists the reasons why they are competent, and supposedly releases us from liability, but what about specific instructions for them? They do not receive a copy of that electronic form. IE- Eat a good meal, closely monitor their glucose levels, make appointment with your MD, call back PRN, etc. I wonder if there are legal problems- other than a false sense of security- with giving out prehospital "discharge" instructions? BTW- I wholeheartedly agree about the support person being there for a diabetic. If there is nobody else at home (usually not the case if the patient was severely incapacitated) you are playing with fire when you allow them to refuse. If all else fails, I have been known to prepare a sandwich for a patient and watch them eat so that I know they won't fall asleep and drop their sugar again.

Since this is a volunteer group, I don't know what specific rules are in place but the person on the scene with the highest level of training should make all decisions made on scene and pertaining to patient care- including the use of lights and sirens. If everyone is at the same provider level, then someone who holds the highest rank may be in charge, or barring that, the most experienced provider on the scene. There needs to be some type of organizational chart (formal or not) that delineates chain of command and job responsibilities and everyone needs to be on the same page with that. Whether or not to provide transport is a separate issue and that is a system policy, not an internal problem to be debated. If you do not have protocols that govern this, I suggest this would be a perfect time to develop them in order to avoid these situations. Paid or not, there needs to be some guidelines to protect everyone- including the patient. Contacting the state is a good idea, and getting suggestions from other systems would also be prudent. Yes, in a perfect world, partners should not be having ego clashes- it should be about the patient, and in most cases, that is the case. Occasionally you get conflicts and someone puts their own issues ahead of the patient's needs and the crew's safety, so back up guidelines need to be in place.

We have protocols as to what to do when patient contact is initiated, but a "patient" is only defined as someone who requests our medical services. Pretty vague, but as we know, it would be impossible to write a rule or SOP for every conceivable situation. At some point we need to use the common sense we were born with along with our medical training and experience. Well, I think in many cases, definitions like this are intentionally vague for legal reasons. I would also distinguish between patient and patient contact. To me, a patient is someone or someone else- who requests medical care for someone unable to ask for themselves. That would mean that a 3rd party call that was a mistake, a homeless guy merely sleeping, an uninjured MVC victim who only wanted the police for a report, an invalid assist, would not really be a "patient". If a person says I did not call, I am not ill, and I do not want or need EMS, then is that person really a "patient"? Obviously a lawyer would probably disagree with those assumptions, but in a busy urban system, if you had to generate a full report, a full set of vitals, perform a complete exam, obtain a complete medical history, and document a refusal for every one of those situations, the entire system would grind to a halt. Write a brief note to appropriately explain the situation and move on.

The assumption here is that the person is a known diabetic. If not, at 71, that person needs to be transported. Take a good history once they are alert and find out why they became hypoglycemic. What are their other medical conditions and medications that may contribute to their drop in sugar? Did they forget to eat or eat less than usual? Did they take too much insulin? Did they fall asleep- or slept in late before they got a chance to eat? Did they engage in more physical activity than normal? Are they brittle diabetics- meaning their glucose levels fluctuate wildly and are difficult to control? Are they long time diabetics or new onset? Are their vitals abnormal in any way? Any other complaints, signs or symptoms? Do they have someone else to keep an eye on them? Can you ensure they will eat an appropriate meal before the sugar boost wears off? If I get satisfactory/reasonable answers to all these questions that could explain their drop in glucose levels, then I am more comfortable in allowing them to refuse. Personally, I would always rather transport vs obtaining a refusal, and I always encourage them to take a ride with us. It takes far more documentation and justification to allow someone to refuse than it does to simply transport them. Bottom line- it's up to a competent person. If you explain the risks, consequences, etc, it is their choice to refuse. Advise them to follow up with their endocrinologist or personal MD. As always- document with medical control. Another facet of this is the almighty dollar. Many folks do not want the added expense of an ambulance ride and an ER visit. Their insurance may not be great or is nonexistant, they do not want to miss work, they have child care issues, etc- and I feel for these people. It's a tough call and in a perfect world, money is no object. Gawd knows this is not a perfect world.

A "mistake" is accidentally giving 3mg of Morphine instead of 2. A "mistake" is documenting incorrect vital signs. Refusing to respond to a call is NOT a mistake, it's a dereliction of duty and goes against everything we are supposed to be about. That person should never be allowed to provide EMS again, IMHO. This situation was not about the provider's level of training. If an ALS intercept was not an option, then the EMTB's would have had no choice other than "diesel therapy". If I were the family member of that patient and found out that someone refused to come to the aid of my relative, my first goal would be to have that person's license revoked. Barring that, I promise that I would do everything in my power to make sure that provider would be punished to the fullest extent allowable by the system policies.