Instruction in what to do.

[Happiness]

As being one of the highest seniority and skill level, I am one of two that get to do the field training of the new ones out of school. I am not always the most articulate person but I always try to teach them that they should treat their pt the same way that they would want themselves to be treated or their family members. I was very lucky to have instructors that actually said "Think outside of the box" and it does stick in a students mind.

When we go on the first couple of calls I will say to the newbie this is your call, do what you need to do and remember your training, I will be there with you and if you start to feel overwelmed I will step in. We will go over the potential senerios on our way to the call. They do the call and then we go over it again at the station.

Now since I have been in the community for so many years everyone knows that I have been doing this for a long time, when we get to the pt I will introduce my partner and state that they are new and do you mind if they attend to your needs, not one pt has refused.

Now with all the above gobbly goop I dont think I would have stepped in on your newbie (But with that being said I wasnt there to see him/her fumble), I might have taken him aside at the scene (in private and if the pt was stable) and had a teaching discussion so that they could get back on track. I would have suggested that the student start a line of questions on why did the pt fall ie. did they trip, were they dizzy ect. When you are dealing with the elderly they really are the type of pts that need to have many more classes devoted to them and the special needs that they present. The problem with schools is that most will teach you what is in the book and not in the field. When I started we were taught ABC"S and dont deviate from that, but what they didnt say was that you may not get past A.

I dont know if my comment is pertenent to your question but I hope it gave you something.

Have a good day

[crotchitymedic1986]

Sorry Dwayne I have to disagree. Regardless of the situation, the OP is searching for an answer to educate students or newbies about these type of situations. Yes, this one is pretty easy, but I say you should involve a supervisor and/or MC anytime you encounter a problem where you do not have a protocol or policy to protect you. Not because you are too stupid to figure it out, but because it gives you another layer of cover should it "go sideways" as you state. For this particular call:

1. The woman is 100, anyone over the age of 70 with any medical problem or injury should be transported, if you can talk them into it, regardless of how stable they appear. If you newbies do not learn anything else from the crotch, transport everyone over 70 and all drunks.

2. He states he could not auscultate a B/P

3. The patient could not ambulate under her own power.

4. You have no idea how long she had been on the floor.

5. Unless you have mobile CT or xray, you have no way of knowing if she had a TIA/Stroke or fractured a bone during the fall.

A more experienced supervisor may have been able to talk her into going to the hospital, if not, you can then show that you went above and beyond to get her to go. Do you really think she isn't going to fall again ?

Hey let's go there. Same hair dressor comes back that night to check on her, and finds her dead. The family is outraged that you did not transport her the first time, and did not attempt to call them when you were out there the first time. You really want to defend leaving this patient at home ? Here is my first "lawyer question" - How long were you on the scene ? 15 minutes, 20 minutes ? Wow, you really went out of your way to help her, let me guess, you wanted to get back to the station so you could watch TV, sleep, or eat ?

Did I change anyone's mind ?

[Richard B the EMT]

1. The woman is 100, anyone over the age of 70 with any medical problem or injury should be transported, if you can talk them into it, regardless of how stable they appear. If you newbies do not learn anything else from the crotch, transport everyone over 70 and all drunks.

2. He states he could not auscultate a B/P

3. The patient could not ambulate under her own power.

4. You have no idea how long she had been on the floor.

5. Unless you have mobile CT or xray, you have no way of knowing if she had a TIA/Stroke or fractured a bone during the fall.

1) FDNY EMS protocols say, any patient wanting to RMA/AMA (Refuse Medical Assistance/Against Medical Advice), who is under 5 years of age (parents acting on the youngster's behalf, obviously), or over 65 years of age, has to be cleared to do so by the OLMC doctor.

2) Couldn't hear or feel a BP? I'd be hearing alarm bells, as the BP might be too low to be ascertained. There's something happening here, what it is ain't exactly clear.

3) Cannot move on their own? Sounds like they might be taking a ride with you. Also, looking back at #1, the OLMC doctor will ask if the patient can ambulate, and how well they can do so, as witnessed by you and your partner.

4) I admit I had not previously thought of the down-time element. Good catch.

5) NY State DoH testing has one doing a total head to toe "unconscious patient" evaluation. Looking for broken bones, now might be a good time to do one on our patient. Admittedly, this doesn't have any indicators in the survey to account for TIA/CVA activity.

One thing the FDNY EMS Command's OLMC does, sometimes, is allow a patient, whom we've placed back in bed, to remain unattended for at least overnight, IF we have some confirmation that someone is going to look in on them the next morning.

Admittedly, if the patient is not expecting a home care attendent, a "paid patient companion", or a family member, OLMC will ask for the local EMS field supervisor and the LEOs with THEIR local field supervisor to meet you at the scene, especially if the patient needs to be placed into "protective custody" pending regular and/or psych ER evaluations. That way, the lawsuit goes to NYC's legal offices, before coming back at the LEOs on the scene, and your EMS team, should the patient sue for us "kidnapping" them. The EMS team then is operating at the behest of the NYPD. We may still be sued, but I have never heard of anything beyond the annoyance of being sued happening, as in no penalties ever came of it.

[P_Instructor]

Down time short period. Patient stated had been up and down thru morning, latest event about 30 minutes. Denies unconsciousness at any period of time. Yes the non-auscultated BP did 'alarm', but further investigation due to cooler extremities, age, size, etc, carotid pulses were present and regular with adequate strength. Not all 100's have a pressure above 100. Further assessments of vitals were obtained during the course of the call, did leave patient with pressure in 108 systolic range, no neuro deficits, no complaints either from patient or family. Hairdresser actually remained with the patient for rest of day and thru evening per our/family/her request and patient approval.

1. The woman is 100, anyone over the age of 70 with any medical problem or injury should be transported, if you can talk them into it, regardless of how stable they appear. If you newbies do not learn anything else from the crotch, transport everyone over 70 and all drunks.

Rply: You have the patient that has all their facuties, is over the age of 70, has no complaints, and doesn't want to go.........kidnapping.

2. He states he could not auscultate a B/P

Rply: Look for other ways to determine perfusion. BP is the last thing you are using to determine inadequate perfusion. If you can't other determinants of inadequate perfusion and have to rely on BP, get more instruction. Waiting for the BP to determine shock.....your patient will die.

3. The patient could not ambulate under her own power.

Rply: How many 100 year olds have you seen actually be able to do the 'tango' effortlessly.

4. You have no idea how long she had been on the floor.

Rply: 30 minutes

5. Unless you have mobile CT or xray, you have no way of knowing if she had a TIA/Stroke or fractured a bone during the fall.

Rely: That is what physical assessments are utilized for. Good assessment tools give you that information.

A more experienced supervisor may have been able to talk her into going to the hospital, if not, you can then show that you went above and beyond to get her to go. Do you really think she isn't going to fall again ?

Rply: I will not address this statement any further than with my 30+ years of experience, you should know what is best for the patient......talking them into something is not always the best circumstance and could create more problems......even legally.

Did I change anyone's mind ?

Not mine.......

[fakingpatience]

Not specifically to this scenario, but I have to disagree with what has been said by a few people here. I do not think I would necessarily call medical control for this patient unless something in her presentation made me uncomfortable leaving her alone. Crochity, you say that anyone over 70 with a medical complaint should be transported. What are you defining as a medical complaint? I don't know to many people over 70 who don't have a medical condition that they live with day in and day out, that sometimes flares up.

Here is what I would do/ want to know were I in a similar situation

First, instructor, you say carotid pulses are present. What about radial pulses? I assume they were as later you state a pressure with 108 systolic. If I am having trouble ascultating a pressure, I attempt to get one by palpation, then either have my partner, or the monitor try. After obtaining baseline vitals with the pt on the floor/ how we found her, and doing a basic assessment, I would then assist her to sitting. At this time I would reassess vitals, check how she is feeling, and do a more detailed exam. If nothing is hurting and vital stay the same, I would then assist her to standing. How does she normally walk? Independently or with a walker? Does she use a wheelchair for distances? If she is is able to ambulate around her house (get to and from bathroom/ kitchen), I would be comfortable letting her refuse, while encouraging her to call her doctor for an evaluation for frequent falls, and having a plan for friends/ family to come over to stay with her for a while. (NOTE, this is based upon her earlier statement that falls are due to feeling unsteady on her feet/ increased weakness, NOT dizziness...). If she does not have a walker, she probably needs an evaluation for one, which they will not do in the ER.

If I get pt to standing and she is unable to ambulate independently/ with her walker, I would have her sit back down and we would have a discussion. I would tell her I don't feel safe leaving her at home alone when she can't get around. What if she needs to use the bathroom again, how will she get there? I will try and point out realistic problems that she can/ will have if she is unable to walk. I will encourage her to call her family/ friend, and if it is OK with her, explain to them what is going on, and try and have them convince her to be transported. If pt is adamant she will not go by ambulance, I will bring up the option of having family/ friends drive her to the ER. If she is still refusing transport, I would document and have her sign a refusal, and have someone else present sign as a witness. In this scenario, I would consider calling med control, but unless she has a physical complaint other than increased weakness, I doubt they are going to want anything to do with it.

As far as how to teach your student/ new person this, sometimes the best thing to do in these situations is watch. I am still a relatively new provider, and I am thankful that I had the opportunity to watch different EMTs and medics with much more experience then I deal with these types of scenarios, so I got to pick out parts that each one of them used, and put them together in my own style. Then when I became more comfortable, I started running the entire call on my own, with them watching (actually they said "we will not do anything including getting vitals unless you specifically ask us to") only jumping in if I was going to miss something major.

[Richard B the EMT]

Let me reiterate, here: the FDNY EMS Command's protocol for RMA/AMA with patients over 65 years old is age driven. It doesn't make a difference if the EMTs or Paramedics feel comfortable accepting that patient's RMA or not, although they can advise the OLMC doctor of their comfort level, or suspicions on patient illnesses/conditions.

Sometimes the OLMC will accept the RMA when the onscene crew feels the patient should go, or deny it, when the crew feels the patient is good to be left home. the main thing is, over 65 and wanting an RMA, OLMC MUST be contacted, per our protocols.

[fakingpatience]

Sometimes the OLMC will accept the RMA when the onscene crew feels the patient should go, or deny it, when the crew feels the patient is good to be left home. the main thing is, over 65 and wanting an RMA, OLMC MUST be contacted, per our protocols.

So what happens when OLMC denies the RMA? Do they issue paperwork to put the patient on a medical hold? Who carries out the paperwork if the patient adamantly refuses? Do you do everything necessary including taking the pt using force into the ambulance? Do police get involved at place the patient in their custody? Not saying you are wrong here, just honestly trying to understand what happens if the OLMC says the pt cannot refuse.

(sorry to hijack the thread)

[usalsfyre]

So what happens when OLMC denies the RMA? Do they issue paperwork to put the patient on a medical hold? Who carries out the paperwork if the patient adamantly refuses? Do you do everything necessary including taking the pt using force into the ambulance? Do police get involved at place the patient in their custody? Not saying you are wrong here, just honestly trying to understand what happens if the OLMC says the pt cannot refuse.

(sorry to hijack the thread)

I agree, I'm not sure how a base physician could "deny" a patient refusal. Doing so amounts to kidnapping without the appropriate legal maneuvering.

[DwayneEMTP]

Crotchity, no need to apologize, disagreement is how we learn here.

Again though, she is mentating normally, she has a right to refuse. I think that perhaps your argument is based more on trying to keep the newer, younger providers from getting jammed up by driving outside of their lane, but that will also blow smoke up their skirts.

As she's mentating normally, do I believe that contacting medical control is a week, or stupid thing to do? Of course not. I do agree with you that if you have questions you should seek support. I just simply didn't have those questions as this case was presented.

I as well am curious what the protocol states should happen after the doc denies their refusal? The more important element in my mind is whether or not I'm willing to cheat this person out of their right to control their own destiny when I believe that ability to understand all concerning that right is intact. Many of these people have survived two world wars, a gazillion 'actions', the great depression, built a huge part of the world that I now enjoy, and I refuse to take the removal of their right to be an autonomous human being from them lightly.

I've got no beef with medcon, but if they want to refuse my refusal, then they'll need to come an do it in person. For me it still goes back to pt advocacy. We seem sometimes to be losing sight of the fact that that is at the very center of paramedic medicine. Am I safer if I trick or bully everyone over 70 into going to the hospital? Of course, but I'm safer at the cost of giving up being a good paramedic.

Dwayne

[Richard B the EMT]

As I previously said...

Admittedly, if the patient is not expecting a home care attendent, a "paid patient companion", or a family member, OLMC will ask for the local EMS field supervisor and the LEOs with THEIR local field supervisor to meet you at the scene, especially if the patient needs to be placed into "protective custody" pending regular and/or psych ER evaluations. That way, the lawsuit goes to NYC's legal offices, before coming back at the LEOs on the scene, and your EMS team, should the patient sue for us "kidnapping" them. The EMS team then is operating at the behest of the NYPD. We may still be sued, but I have never heard of anything beyond the annoyance of being sued happening, as in no penalties ever came of it.

Also, quoting Charles Dickens, "The law is a Ass!" When I first heard this from my EMS Academy instructors, we all were shocked: EMS is NOT allowed to make a field decision that a person is a presumed EDP, but an NYPD Officer IS. Hence, on the officer's determination, NYPD takes the patient into "Protective Custody" to protect the patient from thenselves, and EMS ends up, basically, just supplying the transportation to the ER.

Youy bet your Bippy, the patient will be cuffed during transport, and, as the LEO won't go too far from their handcuffs, will ride in the back with the patient and EMT or Paramedic "riding shotgun" that tour.