What did EMS miss if anything

[DwayneEMTP]

I can't think of anything that should have been done that was not done according to the OP's report so not sure what you think he missed?

I made it clear that I don't believe that he missed 'doing' anything.

... You also have made an assumption that because he realized the pt was old and (probably) dying that he did not work them up adequately whereas it seems that the appropriate treatments and measures were taken. (i.e. 12 lead looking at the chest pain as well as treating as a trauma pt as far as I can tell).

Again, you're trying to tag me with that assumption. I claimed that he didn't report it correctly. Or, perhaps you can correct me, what is a normal set of vitals signs for a 90 year old male in this situation?

...He may have been looking back in hindsight and understanding that the pt's co-morbidities were the cause of his death versus any lack of care on the medic's part.

You'll need to quote the part of my post where I claimed that the medics played any part in this pts mortality.

...It is also an assumption that taking note of his age and condition caused them to decrease their level of suspicion for occult injuries and complicating factors whereas he did not say whether or not it may have instead raised their alertness to more potential complications.

Had it raised his suspicions I would have expected that he would have told us in what direction his suspicions pointed him. Are you truly going to tell me that you've not seen new and seasoned medics alike that have been dispatched to a "drunk" and were nearly unable to see anything upon arrival besides a drunk? This is a post call review, in which he states that his personal view is that the pt was old and dying. That is a very weak diagnosis, and one that I don't believe he should be happy with now, nor feel comfortable making in the future. Something was killing this patient while he was in this mans care, and something finished killing him two days later. What I was wishing for him is that he would have a 'feel' for what was going on anatomically/physiologically and not be satisfied with "He's old and dying." I've witnessed the deaths of many, many "old and dying" people and very rarely has their death come from a common cause. And very rarely was a unable to get at least a hint of what that cause may have been. I wish that for him.

...He was obviously taking into account the geriatric considerations or else he would not have been saying that "as far as 90 y/o patients go he was very healthy and I hope to be that healty [sic] at his age".

Agreed. He considered the fact that he was old. But again, failed to report which aspect of being old the he believed was killing him. According to what was reported, this was a perfectly healthy 90 year old that died. No history, no abnormal assessment values, no pain. So....why did he die? I hope for him to need to know that.

My criticism was hoped to have cause two things to happen. First, convince this young new medic that being criticized is the life blood of EMS, that it's GOOD to have people tell you that you were weak in places, in this case case reporting, so that you can become stronger.

Second, to allow him to come back and speak for himself. A very necessary medic skill and something that I know for a fact he is perfectly capable of, and in doing show others here that may be more timid that having a spirited debate is not the end of the world. See?

Though I do applaud you for coming to his defense.

Dwayne

[Richard B the EMT]

If the man was in hospital for 2 days before dying, whatever ailed him at the time of the car accident may not have been evident enough for either EMTs or Paramedics to diagnose. The ER staff, or the people on floors might have caught on after you turned care over to them, so it might not even be something covered within our scope of practice.

Did the hospital advise you of what happened after transfer of care to them? It might have been something not told you in the patient's history that suddenly went acute.

Also, do not jump to conclusions, and tell your classmates that, too. There's the old story of a man went home, early, from a dinner party because he didn't feel well. With the party still in progress, the hostess got a phone call that he died. She rushed everyone, all the remaining 15 guests, to the hospital, where they all had their stomaches "pumped", fearing it was her cooking. Then, they all found out he died, because he got hit by a truck while crossing against the traffic light!

Edited December 8, 2010 by Richard B the EMT

[Aussieaid]

I made it clear that I don't believe that he missed 'doing' anything.

It didn't come across clear that you were commenting on his lack of vs in his report. Or that you believe he was missing the bigger picture not the treatment and assessment details.

Again, you're trying to tag me with that assumption. I claimed that he didn't report it correctly. Or, perhaps you can correct me, what is a normal set of vitals signs for a 90 year old male in this situation?

You'll need to quote the part of my post where I claimed that the medics played any part in this pts mortality.

I was not saying you claimed the medic's missed something in this sentence but rather conjecturing where his comment about the pt being old and dying was coming from. See how easily things are misread?

Had it raised his suspicions I would have expected that he would have told us in what direction his suspicions pointed him. Are you truly going to tell me that you've not seen new and seasoned medics alike that have been dispatched to a "drunk" and were nearly unable to see anything upon arrival besides a drunk? This is a post call review, in which he states that his personal view is that the pt was old and dying. That is a very weak diagnosis, and one that I don't believe he should be happy with now, nor feel comfortable making in the future. Something was killing this patient while he was in this mans care, and something finished killing him two days later. What I was wishing for him is that he would have a 'feel' for what was going on anatomically/physiologically and not be satisfied with "He's old and dying." I've witnessed the deaths of many, many "old and dying" people and very rarely has their death come from a common cause. And very rarely was a unable to get at least a hint of what that cause may have been. I wish that for him.

Agreed. He considered the fact that he was old. But again, failed to report which aspect of being old the he believed was killing him. According to what was reported, this was a perfectly healthy 90 year old that died. No history, no abnormal assessment values, no pain. So....why did he die? I hope for him to need to know that.

My criticism was hoped to have cause two things to happen. First, convince this young new medic that being criticized is the life blood of EMS, that it's GOOD to have people tell you that you were weak in places, in this case case reporting, so that you can become stronger.

I do understand what you were trying to achieve here and agree with your cause. I just feel that there are ways to achieve constructive criticism without making it personal and making judgments about where a person is coming from when there is not enough information given to do so. I just didn't think there was enough info about what he was thinking in relation to the pt's age to warrant a "shame on you" comment. (That was the comment I had an issue with as it was rooted in assumptions.) Believe me I do understand where you are coming from and agree with 98.75% of your comments.

Second, to allow him to come back and speak for himself. A very necessary medic skill and something that I know for a fact he is perfectly capable of, and in doing show others here that may be more timid that having a spirited debate is not the end of the world. See?

I do see and enjoy a spirited debate myself on occasion which is probably more to why I responded to your comments than taking any offense myself!

Though I do applaud you for coming to his defense.

I am afraid I just get a little annoyed with how so many professions feel it is necessary to teaching to "eat our young". The OP posted to get more advice and asked for thoughts on how to improve and seemed to be open to positive feedback (constructive criticism). Some of the postings came across unnecessarily harsh in light of that. Just because everyone does something that does not make it right. (EMS criticism). Yes, we need to be open to feedback so we can improve ourselves but it can be achieved with mutual respect and that will make people more willing to open themselves up to critiquing and learning. The ones who ask for advice or feedback are the ones who want to improve and learn and they should not be made to feel bad when doing so no matter what they may have done wrong or failed to do. Otherwise all they learn to do is not ask for advice (to theirs and their pt's detriment) and become defensive when questioned on something.

Dwayne

I am not sure I explained myself to my satisfaction but it will have to do for now. I am probably just a little too sensitive to QA processes at the moment and reacted more to how the post came across than the intent of the post.

Cheers anyway,

Aussie

[DwayneEMTP]

...It didn't come across clear that you were commenting on his lack of vs in his report. Or that you believe he was missing the bigger picture not the treatment and assessment details.

..I don't think that there were any skills that you didn't perform that you should have.

Though I'm not sure that I completely understand the rest of what you said above...

..I was not saying you claimed the medic's missed something in this sentence but rather conjecturing where his comment about the pt being old and dying was coming from. See how easily things are misread?

Yeah, I see that now. My apologies for misreading it before.

...I do understand what you were trying to achieve here and agree with your cause. I just feel that there are ways to achieve constructive criticism without making it personal and making judgments about where a person is coming from when there is not enough information given to do so. I just didn't think there was enough info about what he was thinking in relation to the pt's age to warrant a "shame on you" comment. (That was the comment I had an issue with as it was rooted in assumptions.) Believe me I do understand where you are coming from and agree with 98.75% of your comments.

I do believe that there are other ways to state the opinions that I make, and gentler ways. But I'm not good at those ways, as I try and focus on being clear over being kind, sometimes to the detriment of my goals. Also, if there is a gentler way, I don't necessarily believe that it is a better way. Paramedic medicine in my experience is physically, mentally and emotionally a contact sport. I have had people light into me both guns blazing over decisions that I have made. They don't tend to fare well, as I'm not terribly delicate, but many that come here initially, and many leaving school now, tend to be. I believe that we should feel obligated to help increase all of the necessary skills we all need to succeed in our chosen profession. Being able to accept and respond to productive criticism is one of those skills I believe, and a vital one at that.

The "you should be ashamed" comment gave me a little 'ping' when I typed it though it was meant in the "Assie, shame on you for telling that blond joke AGAIN!" vein, though I can see now that it certainly didn't come across in that spirit when typed. Thanks for bringing to my attention. But again, it's my feeling that the OP has more than the necessary intestinal fortitude to say, "Fuck you and your 'shame on you', this is what I was thinking..." and would have been the better for the exchange. And all EMS criticism is very personal isn't it? Unless there is another medic on my truck that I'm unaware of, any criticism that comes from my truck, my care, my decisions or my documentation are aimed at me or mine. I think that that is very personal. And we'll stop eating our young when we teach our young to have enough self respect that they stop walking around looking like snacks, right?

... The ones who ask for advice or feedback are the ones who want to improve and learn and they should not be made to feel bad when doing so no matter what they may have done wrong or failed to do. Otherwise all they learn to do is not ask for advice (to theirs and their pt's detriment) and become defensive when questioned on something.

Agreed, with one exception. Though it shouldn't be our goal to make others feel bad for their opinions, how often do we see noobs or students post their questions or comments, have them questioned, and then never hear from that person again? Do you feel that it's healthy in our profession to be so delicate that having someone question your thoughts, in an appropriate manner, should create such a debilitating condition that they are unwilling to post a reply? (Not what I think is happening here by the way. Medic school is busy I know, so I'm confident that the OP is busy, not hiding.) Do we help them, or our profession by attempting to wrap each response in velvet so that there can be no possible offense drawn from it? How does one advocate for their patient when they are unable to advocate for themselves?

Learning to stand up for yourself and your opinions is a skill not much different than learning to tie your shoes or spoon cereal to your mouth. It needs to be practiced, in different ways, in different places, under different levels of duress before it can be counted on. I tend to find posting here to be stressful sometimes believe it or not!! I have a lot of respect for the opinions of many here and hate it when i come off looking like a monkey fucking a football secondary to one of my best thoughts. But that is the value here too. Thinking before posting has taught me to formulate my thoughts much more clearly and completely before posting, and that habit has infected the rest of my professional life as well. I speak more properly, present myself better because of many of the lesson I've learned here.

When we attack our 'young' we teach them insecurity and fear, when we coddle them we teach them to be weak and impotent, I strive for, though admittedly often miss, a middle ground of professional respect, where I neither disrespect them for their opinions nor disrespect them by assuming that they are unable to tolerate adult debate. It is always my intention to treat them with professional adult respect, though at times I do try to challenge those that seem up for it, so as not to let them get bored.

I believe that this conversation is an excellent example of what I mean. My post was far from perfect. You attacked it in an intelligent, kind way, and in the very best spirit of what we do here, and I, as well as others I hope, have learned from that. Very little intelligent debate can happen here if people are going to faint at the first sign of adversity, yet too often I seem to see that happening. I'm grateful for your response, and for finding me and my opinions important enough for you to sacrifice time our of your busy day to correct. That's cool as hell.

Have a great day all....

Dwayne

[Aussieaid]

Thanks for your kind response.

I think what I was really trying to get across is that people can critique in a respectful way without necessarily being so "gentle and kind" that it is basically ineffectual. It is just showing simple respect to each other and I am not accusing you of being disrespectful just generalizing. Sometimes it is a simple matter of putting yourself in the other person's place and realizing that a mistake may be made because of simple lack of knowledge and just requires education to fix (just an example). We also all have our off days and just miss things or have "duh" moments. I'm usually much harder on myself than anyone else is so when people talk to me in a disrespectful way it just tends to make me defensive and not receptive to their feedback. It's like telling a child that they did something that was bad (or wrong) not that they are a "bad boy/girl". That's what I meant by making it personal.

I also understand that there are certain times in our field when you can't be worried about how someone will take a correction especially when there are pt's at risk. That's why we have debriefing. I think though that when people are willing to post on forums they are actively seeking to better themselves and further their education and agree with you that hopefully they won't scare off easily.

I would hope that people would be willing to step up to the plate and continue to educate themselves if someone provides them with constructive criticism.

And we'll stop eating our young when we teach our young to have enough self respect that they stop walking around looking like snacks, right?

I find that there seem to be too many newer folks who think they have all the answers and are not willing to ask questions and look for feedback. Perhaps you could call it a "surfeit of self respect". That is why I don't like to be unnecessarily harsh when someone is truly looking to increase their knowledge and willing to learn from more experienced folks. Nurturing doesn't have to be all frills and flowers. I find I am way more willing to ask someone questions when they are actively interested in teaching me and treat me with simple respect without making me feel small for asking.

I'm grateful for your response, and for finding me and my opinions important enough for you to sacrifice time our of your busy day to correct.

"Tongue in cheek" or face value????

I honestly appreciate the way you interact with people on here and applaud you for your efforts in educating others. I am often guilty of having my written word misinterpreted as it is very hard to get the correct tone across sometimes. People often misunderstand my spoken word anyway and totally miss my dry humor!

Sorry to have hijacked the thread....and now back to our regularly scheduled responses......

Cheers and Happy Holidays to all!

[DwayneEMTP]

Face value. :-)

Dwayne

[armymedic571]

If the man was in hospital for 2 days before dying, whatever ailed him at the time of the car accident may not have been evident enough for either EMTs or Paramedics to diagnose. The ER staff, or the people on floors might have caught on after you turned care over to them, so it might not even be something covered within our scope of practice.

Did the hospital advise you of what happened after transfer of care to them? It might have been something not told you in the patient's history that suddenly went acute.

Also, do not jump to conclusions, and tell your classmates that, too. There's the old story of a man went home, early, from a dinner party because he didn't feel well. With the party still in progress, the hostess got a phone call that he died. She rushed everyone, all the remaining 15 guests, to the hospital, where they all had their stomaches "pumped", fearing it was her cooking. Then, they all found out he died, because he got hit by a truck while crossing against the traffic light!

Richard,

I need to apologize. I went to give you a plus one and hit the negative 1.

I am very sorry, because I like your post, and as usual, it is well versed in experience.

Please do not take offense to my amateur mistake.

Jeff

[mobey]

I went to give you a plus one and hit the negative 1.

Negative point neutralized

Mobey

[RomeViking09]

For the record, He he was old and dying was a post call view 3+ days latter, my impression and treatment was based on elderly man in minor distress who happened to be in a minor MVC on the way to the ER. I did a full assessment and treated based on that assessment and got him to the ER, at the time I did not see any reason he would end up dead in less than a week as a result of his complaint or the MVC. As far as cause of dead I don't know and the medic I was riding with did not say. Glad to see good input at the same time think some folks missed what I was saying in my 2nd post. That was a view after the fact based on what I had seen in my time with this patient.

[Eydawn]

Dwayne- there's simply not enough information to go on here. He was feeling sick, his wife was already taking him to the ED... unknown patho on what was really making him feel sick in the first place and no prehospital tests or indicators in history given that could really lead you to the "aha! (maybe?)" moment, as far as I can tell.

There is no "normal" for someone in their 90's. Trust me on this! There is normal for THEM.... but a true norm? I'll believe that when I see it. There's so many factors that go into vitals for the elderly, including polypharmacy, past history, lifestyle for 80+ years, work exposures, what they ate yesterday, how much they slept (if at all), have they pooped in the last week... it goes on and on here.

Without a 12 lead in front of us to actually look at, no way to really know if it was cardiac (which is my suspicion, based on the nitro hx) when it could have easily been neuro, or metabolic... there are so many things that go wrong that make our elders feel "weak" or "sick" and without a detailed history from the past month and knowledge of all his prior conditions, there's no way to tell what he was dying of. Sometimes, even when you have all that info, you still can't figure it out (you meaning both prehospital, me, in my facility where we care for them before we send them out with you, or the hospital itself...)

I agree that to just assume that someone is old and dying is foolish, but, nobody is JUST assuming that- it is just one possibility in with many others. Sometimes they just freakin' die! It happens. The fact that he was admitted to the hospital indicates that there was some kind of issue that needed medical monitoring, but without the chicken, so to speak, (AKA what he was admitted and monitored for) it's hard to look back and see exactly what flavor egg might have been lurking while you were transporting the guy...

I think the major issue here is that these classmates of Viking's are assuming that because the patient died, there is something that could have been detected by EMS that was missed. This is an erroneous assumption, and while criticism and self-examination are great learning tools they need to be used appropriately. It's not about "he died so you must have missed something" but rather should be more along the lines of "hey doc, do they know what that guy was admitted for and how he died? Ok, let's look back at the call and see if the evidence we saw points in a different direction now knowing this info..."

I think it's the approach more than anything that people are irked about here. I'm interested to know why he was admitted... but sometimes you don't get to be privy to that info. Pity, because it robs you of great chances to learn more about all this...

Wendy

CO EMT-B