Advice Needed

[Timmy]

First of all this is a vent post but I would really value your opinion.

I had a minor issue recently that I would like your opinion over, I stress minor issue here as nothing catastrophic resulted from it but it’s just been playing on my mind for a while.

As you all know I volunteer some time doing first aid around the place. I was doing a first aid standby recently at the local motocross track, I had a 14 year old come off with pain to his right ankle, there was some localised swelling and 8/10 pain, I splinted it, gave him analgesia, loaded him into the ambulance and waited for the paramedics to arrive as were not allowed to transport from the event. Nothing wrong with the patient himself, the job ran with no problems, text book.

When the two young paramedics arrived I welcomed them into my ambulance and began to give hand over, the paramedic started talking over me so I just stopped talking and sat back. She then gave me the evil eye, stood over me and questioned why I hadn’t applied a collar, I explained there was no MOI, low speed MBA, helmet intact, no LOC, neurological and spinal assessment NAD, full safety equipment worn, no motor/sensory issues so I didn’t see the need for spinal precautions but was happy to put one on if they thought it was indicated. She laughed and made comment at my ‘expert assessment skills and she could only imagine were I got my qualifications from’. Needless to say they did not apply a collar or even do any spinal assessment so I guess they weren’t too worried. They weren’t interested in my neurovascular assessment of his foot so I just left it at that…

She then removed the air splint from his ankle, threw it at me, moved his foot around then told the patients father it wasn’t broken and not to worry. She then looked at me and told me never to waste there time like this again, I clearly had no idea what I was talking about. Anyway, they transported the kid end of story.

The next day I followed up with the hospital, turns out he had a # lateral malleolus, distal tibia and proximal metatarsal fractures which required surgical intervention.

I’m not a bitter person, I’m pretty easy going and what not but the option of writing a letter of complaint was raised. I’m a bit unsure of what to do so I just hand balled it to the patients father, it’s his son, he has the right to complain if he wanted, I’ve done all I can, did my job as best I could… Then I thought, well, if I stuffed up the paramedics are the first ones to jump down my throat on scene then follow it up with a letter of complaint then disjoint your reputation to shreds back at the station, so why can’t I complain?

I mean, just because I have first aid written on my uniform doesn’t exclude the fact that I’ve done a year of paramedics and three years of Nursing at University, I’ve done first responder training, spinal injury care, motorsports rescue training, I’m very familiar with the Hans Device, know the motocross gear like the back of my hand, do education sessions for motocross officials on incident management, talk to all the riders at briefing, they know us, we know them, I know how the motocross guys think and breath, we’ve had the joy of resusing a few kids out there and seeing them back up and riding the next year, I’ve done some riding with them back in my teen days so I know how they operate.

I’ve done over 300 motocross races so I didn’t come down in the last shower but 9 times out of 10 the paramedics will bring you down with some sarcastic comment and make you feel like a retarded Wally. It’s not just this call, they often pass stupid remarks to belittle you. I don’t know if it’s my age, if I look funny or what ever but I’ve really had enough, I shouldn’t have to put on my bullet proof jacket every time I call an ambulance, I do my job well, perform to my scope of practise and have never made any mistakes that would case further harm to the hundreds of riders I’ve cared for.

Sometimes I just think to myself… Why bother going to University full time, working 30 hours of nightshift, then staying up til 3am the morning before finishing assignments so I can volunteer to help the guys out, missing out on weekend work… Just busting my ass to be put down.

I don’t know what to do. I should really just have a cup of cement, harden up and move on I guess.

Edited March 21, 2011 by Timmy

[Lone Star]

Timmy,

I don't know exactly what your scope of practice is, but based on the conversations we've had and the quality of your posts, I can pretty well presume that stupidity is not your problem here.

Based on the information given, I would have done pretty much the same thing. I can understand your hesitancy on full spinal immobilization. Even though my protocols do not allow for selective spinal immobilization, if yours does, then I would have to concur with your actions based on the MOI.

It’s a shame that so many in this field are ‘protocol driven’, even when faced with evidence to the contrary.

I seriously hope that the father of this patient files a written complaint against the attending medic! Considering that you had splinted the affected extremity, and not only did they remove the splint, but manually manipulated the fracture, I’m sure that they didn’t do the kid any good at all.

As far as you filing a written complaint, I would. This is one example of why having a medical director is a ‘good thing’.

The medic's actions were reprehensible at best, and if I were in that situation, I would not only file a written complaint with the local medical director, but I would also file a written complaint with the supervisory staff at their station as well.

Not only were the medic’s actions unprofessional, but they were negligent as well. Can that medic REALLY say with any certainty that her manipulation of the fractured extremity didn’t exacerbate the injury, and thereby cause the need for surgical intervention? Here in the States, her actions could find her in a world of sh*t facing possible malpractice charges....

Since you’re not only experienced in first aid in this arena, but also have participated in this particular event, you are far more qualified to understand the potential mechanisms of injury that these riders face each time they get on the track.

[lpndj6]

I gotta agree with Lonestar on this one. Whats funny is Ive run into the same situation myself but whats funny is once the crews find out that I have previous experience in EMS theyve tended to be a little more professional with me. Ive seen them give other co-workers of mine crap over 911 calls but when they find out Im the one that made the decision that the patient needed to go out they change their tune which I find weird.. I mean yes I spent 8 yrs in the field before going into Nursing that shouldnt make a difference in the end to my estimation we all have our roles we fill in the medical chain of care be it emergency, acute, sub acute, etc.. I mean no offense but any medic questioning a nurse who knows her patients and whats normal and not with them and knowing whats an issue.. Besides I know at least in my facility we always have to get the OK from the MD on call to send them out unless its a blantant medical emergency (IE Code, Unresponsive Diabetic (after TX X1 with Glucagon if Low),) The Charge nurse during shift usually makes the decision if the MD cant be contacted in time (which is me when Im working).. Now I did come across a situation one night which I did actually have an issue with the EMS crew and I did file a complaint. Patient fell down found face down semi-responsive with a previous DX of a spinal fracture (non displaced and non surgical intervention within the previous 2 weeks just prior to arrival at our facility). I had the Aide stay with the patient and hold Cspine while I called MD and then 911 and then took over CSpine after doing quick assessment of the resident awaiting EMS arrival.. They did NO immobilization of the resident just literally picked him up on the sheet he was in. his head was nearly hanging off the end of the cot. Granted fortunately he had no furtther exacerbation of his previous injuries but given his HX and a confirmed Fx I was blown away by their field TX of this patient and even a couple of my coworkers were aghast at what they witnessed.. (BTW no Id never had had an encounter with this particular crew before). But EMS is run by the Hospital System in the jurisdication where i work so getting word back to their MC wasnt too hard.. I dont know the final outcome but I do know that their Supervisor did appologize to us and the family (his wife had been in the room when it happened) for what happened and said it was definitely a deviation from acceptable policy.

PS I got my start under the old EMT-A standards in the early to mid 90s when it wasnt just a med and trauma station along with CPR/AED and you had to actually do random skills up in Virginia which apparenlty they are finally going back to that thank goodness.. IN fact I look forward to moving back to VA next year and returning to doing some field work again once I finish my next step in my nursing career (and after I fully recover from upcoming back surgery which is why I walked orginally from EMS due to back injury and went into Nursing but has finally caught up with me again and now going ot get things fixed for good and probably will finally feel better then I Have for years {Very Bad DDD L4-L5 and L5-S1)

First of all this is a vent post but I would really value your opinion.

I had a minor issue recently that I would like your opinion over, I stress minor issue here as nothing catastrophic resulted from it but it’s just been playing on my mind for a while.

As you all know I volunteer some time doing first aid around the place. I was doing a first aid standby recently at the local motocross track, I had a 14 year old come off with pain to his right ankle, there was some localised swelling and 8/10 pain, I splinted it, gave him analgesia, loaded him into the ambulance and waited for the paramedics to arrive as were not allowed to transport from the event. Nothing wrong with the patient himself, the job ran with no problems, text book.

When the two young paramedics arrived I welcomed them into my ambulance and began to give hand over, the paramedic started talking over me so I just stopped talking and sat back. She then gave me the evil eye, stood over me and questioned why I hadn’t applied a collar, I explained there was no MOI, low speed MBA, helmet intact, no LOC, neurological and spinal assessment NAD, full safety equipment worn, no motor/sensory issues so I didn’t see the need for spinal precautions but was happy to put one on if they thought it was indicated. She laughed and made comment at my ‘expert assessment skills and she could only imagine were I got my qualifications from’. Needless to say they did not apply a collar or even do any spinal assessment so I guess they weren’t too worried. They weren’t interested in my neurovascular assessment of his foot so I just left it at that…

She then removed the air splint from his ankle, threw it at me, moved his foot around then told the patients father it wasn’t broken and not to worry. She then looked at me and told me never to waste there time like this again, I clearly had no idea what I was talking about. Anyway, they transported the kid end of story.

The next day I followed up with the hospital, turns out he had a # lateral malleolus, distal tibia and proximal metatarsal fractures which required surgical intervention.

I’m not a bitter person, I’m pretty easy going and what not but the option of writing a letter of complaint was raised. I’m a bit unsure of what to do so I just hand balled it to the patients father, it’s his son, he has the right to complain if he wanted, I’ve done all I can, did my job as best I could… Then I thought, well, if I stuffed up the paramedics are the first ones to jump down my throat on scene then follow it up with a letter of complaint then disjoint your reputation to shreds back at the station, so why can’t I complain?

I mean, just because I have first aid written on my uniform doesn’t exclude the fact that I’ve done a year of paramedics and three years of Nursing at University, I’ve done first responder training, spinal injury care, motorsports rescue training, I’m very familiar with the Hans Device, know the motocross gear like the back of my hand, do education sessions for motocross officials on incident management, talk to all the riders at briefing, they know us, we know them, I know how the motocross guys think and breath, we’ve had the joy of resusing a few kids out there and seeing them back up and riding the next year, I’ve done some riding with them back in my teen days so I know how they operate.

I’ve done over 300 motocross races so I didn’t come down in the last shower but 9 times out of 10 the paramedics will bring you down with some sarcastic comment and make you feel like a retarded Wally. It’s not just this call, they often pass stupid remarks to belittle you. I don’t know if it’s my age, if I look funny or what ever but I’ve really had enough, I shouldn’t have to put on my bullet proof jacket every time I call an ambulance, I do my job well, perform to my scope of practise and have never made any mistakes that would case further harm to the hundreds of riders I’ve cared for.

Sometimes I just think to myself… Why bother going to University full time, working 30 hours of nightshift, then staying up til 3am the morning before finishing assignments so I can volunteer to help the guys out, missing out on weekend work… Just busting my ass to be put down.

I don’t know what to do. I should really just have a cup of cement, harden up and move on I guess.

[Happiness]

Well if you are thinking of not participating in going to races make sure it because YOU dont want to do it anymore. Why would you hand over the power to those who are ignorant to your skills, so the question is who do you do this for the paramedics or the racers?

It is shitty when you have someone that you think are team mates and they turn out to be the most ignorant pieces of crap on the planet earth. I had a simular situation but I was the paramedic and it the first aid acting like a shit head. Once the call was done (his behaviour continued to the hospital) I found out who his employer was and gave them a call. I talked to a nice guy and once I was done his response was "well I guess thats why he is out in the bush, but please send me a detailed letter and I will deal with it" I did as asked and never heard back. Every once in awhile I would kind of wonder what happened to the guy, until about a month ago, the same guy brought me a guy (turned out to be a arotic anyrism) and he was polite and even said to the pt dont worry you are in good hands. I guess he had someone talk to him. I have also asked paramedics to step out side and have had a chat with them.

I cant tell ya what to do or even give you any advice but if it bugs you to point that you want to stop something you enjoy then you have to do something.

Hope it works out for you, BTW if you look like your avitar your not to funny looking ;-P

[Richard B the EMT]

You know I deal with "First Responder-Defibrillator" trained fire fighters. When I arrive on the scene where they've started patient care, before I ask for their report, I tell them I am still obligated to do my own survey. When I get their report, and do my survey, if I find as they did, I tell them they got it right, otherwise, I tell them, gently, what they did wrong, what to do next time, but still stress what they did right.

Timmy, what these Paramedics initially did is sometimes referred to as "Paramedic Shove". I have heard reports from many associates over the years, sometimes it is actually a physical shove, but it boils down to "Get out of my way, I'm here to save the day! If you are not a Medic like me, you don't exist in my planet."

However, if they removed your splinting, and manipulated the injury site, at least by New York State DoH standards, they committed a malfeasance malpractice. I trust you follow my other mantra, "document, Document, DOCUMENT!" If these Paramedics are within the same service provider as you, go to your medical director with what you've mentioned here, if they are not, have the medical director from your service make formal complaint to their medical director, with documentation to the appropriate medical licensing/certification agency.

As to their rudeness, unfortunately, nobody yet has found a cure for being stupid.

[mobey]

As you know Timmy, I am not one to hold hands and make you feel better, so I will keep this short, sweet, and direct.

Manipulating a fx on a peds pt is very risky especially near a joint. I do not need to talk to you about growth plates, that I know...

If what you presented is accurate: These medics were indeed negligent (Duty to act, breech of duty, possible adverse outcome because of the breech). If there was in fact just a partial Fx as the medic suggested, then by thier own admission they completed it by manipulating it.

You sir, have a duty to report incompetence!

If you let shit like this slide on a peds patient, where do you draw the line?

Do the right thing

Just one mans opinion....

[Just Plain Ruff]

Timmy my friend, I respect you a lot. We've had some good discussions on threads and I know you will do the right thing and report these yahoo's.

The first letter you send needs to be to the management of the service who transported the kid. Manipulating a fracture is bad medicine.

the second letter I would write would be to the state or whoever licenses medics in your locale.

Good luck

[Timmy]

Thanks for your help guys. I think it best if the patients farther submits a complaint, after all I’m not a paramedic so who am I to scrutinise them!

We don’t have mandatory protocols per say, we have similar clinical practise guidelines to the paramedics when it comes to basic life support. We have flexibility in moulding our treatment to interlink with what we find on patient assessment. As I said, I had no concerns about the kids cervical assessment, it’s one of the first things I assess on every rider when they come off. If he fell off riding at greater than 40km/h, had been projected from the bike, had damage to his helmet, had been struck by another bike, had a significant mechanism with a distracting injury or had any symptoms remotely resembling a cervical injury then it’s a completely different story. If I collared every person I went out to see then I’d be filling the local ED with 10 to 20 riders per day!

The paramedics didn’t manipulate his injury, in fact they thought it was not fractured at all. From what I saw they merely removed my splint, did some dorsi and plantar flexion to see if he had pain, which he did. I’m not sure if they re applied a splint because when we transferred him to there ambulance they blocked us out, which is fair enough, I need to get back out to the track anyway.

Is it to much to ask for a little professionalism on a call, it only takes 30 seconds to hand over. I don’t find anything pro active about coming in with a negative blanket over your head, ready to fight just because first aid is on scene…

[Lone Star]

I had a preceptor who ended up having to admit that he had to 'reconsider his initial impression about me' because of an MVA. When asked what drew me to EMS, I explained that I had been an EMT for 12 years prior to this, and I wasn't going to be his 'average student'. He went on to admit that he initally thought my claims of prior experience were bullsh*t. Boy, did he get proven WRONG!!

He's the only one that admitted to his lapse, but I've seen the looks in all my preceptors faces when they ask the same question; and get the same response. Then the look on their faces when I can jump in and run a call (at least to the level of EMT-B)is priceless!

I'm pretty sure that it's going to happen during my clinical rotations for Medic, but hopefully I'll have a better class of preceptors....

The point is, there's far too much of the 'paragod syndrome' running rampant in EMS (apparently it's a world-wide affliction).

EMS needs to remember that they're only a PART of the allied healthcare team, not the team in its entirety, and certain members of that team need to realize that they are NOT ‘God’s gift to EMS’ no matter how many times they’ve convinced themselves of it!

Thanks for your help guys. I think it best if the patients farther submits a complaint, after all I’m not a paramedic so who am I to scrutinise them!

You were directly involved in patient assessment and treatment. Isn’t part of your code of ethics including patient advocacy? If it is, then you’re obligated to report this because the treatment received by the responding medics was NOT in the patient’s best interest. Additionally, you’re someone who is trained to higher medical standards than this medic obviously was, and you KNOW that what they did wasn’t proper!

From what I saw they merely removed my splint, did some dorsi and plantar flexion to see if he had pain, which he did.

Even if the worst that they did was have the patient flex the injured extremity to ‘verify’ that there was pain, unless your protocols or ‘clinical practise guidelines are so poorly written as to support this type of action, that is NOT accepted treatment for a suspected fracture.

Furthermore, by submitting a written incident report and/or formal written complaint, you’ll be lending credence to the father’s complaint as a secondary benefit.

[Emtpbill]

Send a friendly note to the CQI coordinator explaining your actions, those of the medics, and your concerns.

Approach it as an educational angle and you will find the answers you are looking for!