Piping In or Checking Out; The Delicate Balance

[DFIB]

I don't buy into the adage that "EMT's save medics" or any of that bull. I am happy to carry my Medic's bags and learn all I can in the process. I do believe that each member of the team is exactly that, a member of the team. As such I say what I am thinking because I am very aware that everyone misses things, gets distracted, and has a bad night. Even medics.

I don't have any problem with contributing to our patient having the best outcome possible. This is usually not a problem with my partner because I try to turn everything into a teaching/learning moment. If I am wrong in my contribution I learn from it. If I am wright well...you get the picture. Only once have I kept my mouth shut when I should have spoken. I lived to regret it.

[Jaymazing]

Odd. Are you sure that coarse VF is actually on the monitor, and that you're not seeing CPR artefact? This is more commonly mistaken for VT than coarse VF.

..............

Two more bits of weirdness here:

(1) If the patient has been pulseless for some 30 minutes or so, after an initial downtime of 20 mins, there's no reason to transport, this code should be called on-scene.

(2) If we're working a code it's epi q5 until we stop. We don't stop giving meds.

These are surprising actions for a registered paramedic

I, unfortunately, am sure that it was V-fib on the monitor. For the sake of the scenario, I called it "coarse" just to remove any element of doubt. My best guess as to why atropine was given instead of amio would have to be that they both start with the letter 'A'...

As for multitude of other errors made, I completely agree. They are surprising actions for a registered paramedic to make. But I'd like to provide some reassurance by letting you know that the Medic involved is being held accountable for their actions. It wasn't their first time making terrible treatment errors.

You can't really get in a fistfight over this, and try and wrestle the atropine out of his/her hands, or everyone's getting fired, and the patient's family is getting horribly traumatised...

I'm not sure what my reaction will be if I ever see THAT headline on EMS1.com...Possibly a mix of amusement and sadness.

There is no "outranking" in EMS. You're all responsible for the patient, and will be judged as a group. That being said, as an EMT, you're at less risk than any ALS providers on this call, as this is something out of your scope. Other decisions, particularly the problem of a partner wanting to do a refusal on a patient with potential ACS symptoms will put your job at jeopardy as well, even if a paramedic is there. In this situation where an ALS med error was made, you're less likely to get disciplined.

Of course, the point here isn't to not get disciplined -- it's to do the right thing for the patient.

I couldn't agree more. Unfortunately though, I know a few people who think that if it's not their PCR, it's not their problem. But I'm glad to see that you're one of the medic's who encourages a team approach to treatment and patient advocacy.

Thank you for your response! And merry Christmas!

I don't buy into the adage that "EMT's save medics" or any of that bull. I am happy to carry my Medic's bags and learn all I can in the process. I do believe that each member of the team is exactly that, a member of the team. As such I say what I am thinking because I am very aware that everyone misses things, gets distracted, and has a bad night. Even medics.

I don't have any problem with contributing to our patient having the best outcome possible. This is usually not a problem with my partner because I try to turn everything into a teaching/learning moment. If I am wrong in my contribution I learn from it. If I am wright well...you get the picture. Only once have I kept my mouth shut when I should have spoken. I lived to regret it.

I can safely say that I learn more from my mistakes than I do otherwise. That being said, it took me a few too many times flapping my gums when I shouldn't be before I learned to shut my mouth when I should. Unfortunately, I've also made the mistake of being quiet when I should have spoken, and regret it. And thus my quest for the perfect balance began!

[Arctickat]

I, unfortunately, am sure that it was V-fib on the monitor.

I'd like to clear the air here and state that I was not the EMT-A on this call. I am friends with the EMT though,

Okay, I think we're getting screwed around with here. Either you were there or you weren't. You can't be sure it was VFib unless you saw it, but you claim you weren't there to see it.

[DFIB]

Okay, I think we're getting screwed around with here. Either you were there or you weren't. You can't be sure it was VFib unless you saw it, but you claim you weren't there to see it.

You're not the real Santa! You are that old guy that sits on the corner with a bottle all day! Bad Santa!

[DwayneEMTP]

Yeah, there are quite a few things wrong with this scenario as presented...

Only three shocks in 30 mins for continuing Vfib?

Only one round of Epi in the same amount of time?

A decision to transport yet discontinue meds? (Though perhaps with a 30 minute transport, after a 30 minute effort where Epi was pushed properly, it's likely that the truck had no more onboard.)

It sounds to me Brother like your friend is making up stories, or else everyone on scene, not just the medic, needs to be removed from patient care as incompetent...Or, maybe this is a question that you had but didn't think that we'd take it seriously if you presented the scenario other than factual.

Either way, your presentation was intelligent and thorough, you've been participating completely, so I don't really see how these inconsistencies change the context of your question, and I think that it's a really important question. And, I think that you've gotten some really amazing answers...Great job! To my way of thinking, these kinds of threads are the best of what happens in the forums, and yeah, including the discussions as to whether or not this really happened.

Let's try not to derail his thread with other things not pertinent to the OP's real question if we can avoid it...

[DwayneEMTP]

...I felt this scenario was black-and-white enough to keep the focus clear; when is it inappropriate to challenge the medic in charge, and at what point does the risk to the patient outweigh the risk of losing the confidence of the family or seeming unprofessional in the public eye?

This question is just stuck in my head. I can't begin to tell you how much I love it, as it represents the very best of the EMS spirit in my opinion.

It sticks not only because I love it, but because despite thinking about it almost constantly for the last 24hrs, I have no idea how to answer it. Since my first paid day as an EMS provider I've been a paramedic, so I don't really have much context.

I once disobeyed several orders given to me by a doctor that I know, beyond any doubt were dangerous and possibly terminal to my patient, but I just did it. I was alone in the back of the ambulance, I had no question whatsoever that I was given really bad orders, I knew beyond any doubt that calling to get them changed wouldn't get it done as he'd continue to insist that I follow his instructions, so I just didn't call. I changed to my treatment path, things worked out as I'd hoped, I reported the instructions given to me and my reasons for disobeying them to the recieving doc, and they, I assume, took over from there.

The perfect way to resolve your question involves perfect timing, a great approach to the correction, aggressive enough to be heard but not so aggressive as to be ignored, a strong justification for your recommendation, and a medic that's open and willing to hear it all. Yeah man, depending on the medic you're working with, you're likely screwed... :-)

This statement resonates with me, once again from systemet, "If I worked a shift and was allowed to make an error this big, when someone there could have spoken up, I'd be pissed...."

Yeah, me too...As he mentioned in that same post, one of the things that I'm most afraid of is making a preventable error because I'd forgotten something, or was distracted. I will never, ever thank you for watching that happen while you stand quietly by.

[Jaymazing]

Okay, I think we're getting screwed around with here. Either you were there or you weren't. You can't be sure it was VFib unless you saw it, but you claim you weren't there to see it.

I'm sensing a bit of hostility from Arctickat. In response, I'd like to note that I can be comfortably certain that it was VFib without being there, based on several factors, which include:

1) My confidence in the ECG rhythm interpretation skills provided by the EMT who was there.

2) The documentation of the call, which says Vfib was on the monitor at time of Tx

3) My own interpretation of the code summary provided, event markers included (a handy feature, I might add)

and 4) My own experience studying ECG's, and the perception that V-Fib is an easy rhythm to distinguish from bradycardia and PEA. If you disagree that it's an easy differential to make, then your concerns should lie elsewhere. I trust this isn't the case....

So no. I am not "screwing around" with you. And please, try not to sidetrack my discussion, as the purpose was not to discuss treatment methods or ACLS, but to seek advice for the various ethical and moral questions surrounding disagreements made in a public setting.

Thank you for your participation.

Yeah, there are quite a few things wrong with this scenario as presented...

Only three shocks in 30 mins for continuing Vfib?

Only one round of Epi in the same amount of time?

A decision to transport yet discontinue meds? (Though perhaps with a 30 minute transport, after a 30 minute effort where Epi was pushed properly, it's likely that the truck had no more onboard.)

It sounds to me Brother like your friend is making up stories, or else everyone on scene, not just the medic, needs to be removed from patient care as incompetent...Or, maybe this is a question that you had but didn't think that we'd take it seriously if you presented the scenario other than factual.

Either way, your presentation was intelligent and thorough, you've been participating completely, so I don't really see how these inconsistencies change the context of your question, and I think that it's a really important question. And, I think that you've gotten some really amazing answers...Great job! To my way of thinking, these kinds of threads are the best of what happens in the forums, and yeah, including the discussions as to whether or not this really happened.

Let's try not to derail his thread with other things not pertinent to the OP's real question if we can avoid it...

I regret to inform you that I did not alter the medications given, nor the timing of the call (though I did round the numbers, for the sake of making the math easier). There were many faults made, but unfortunately some medic's do not listen to reason in high-stress situations. To make matters worse, the EMT was still fairly new, and rather shy as well.

This question is just stuck in my head. I can't begin to tell you how much I love it, as it represents the very best of the EMS spirit in my opinion.

It sticks not only because I love it, but because despite thinking about it almost constantly for the last 24hrs, I have no idea how to answer it. Since my first paid day as an EMS provider I've been a paramedic, so I don't really have much context.

I once disobeyed several orders given to me by a doctor that I know, beyond any doubt were dangerous and possibly terminal to my patient, but I just did it. I was alone in the back of the ambulance, I had no question whatsoever that I was given really bad orders, I knew beyond any doubt that calling to get them changed wouldn't get it done as he'd continue to insist that I follow his instructions, so I just didn't call. I changed to my treatment path, things worked out as I'd hoped, I reported the instructions given to me and my reasons for disobeying them to the recieving doc, and they, I assume, took over from there.

The perfect way to resolve your question involves perfect timing, a great approach to the correction, aggressive enough to be heard but not so aggressive as to be ignored, a strong justification for your recommendation, and a medic that's open and willing to hear it all. Yeah man, depending on the medic you're working with, you're likely screwed... :-)

This statement resonates with me, once again from systemet, "If I worked a shift and was allowed to make an error this big, when someone there could have spoken up, I'd be pissed...."

Yeah, me too...As he mentioned in that same post, one of the things that I'm most afraid of is making a preventable error because I'd forgotten something, or was distracted. I will never, ever thank you for watching that happen while you stand quietly by.

I'm really glad that the question resonates with you, as it's one that has been on my mind for a while. As you realized, the point of the scenario was simply to paint a black-and-white picture for which to give the question context. Obviously, it's not all that uncommon of a problem, though sometimes the results can differ drastically.

I'm lucky in that I don't often work with bad medics, however there's always the occasional casual or burnt-out medic that gives the rest of us a bad name.

I think this question is something that could almost benefit from being brought up in EMT school, during discussion about ethics and moral obligations. As a student, I always just assumed paramedics knew everything.

An open mind is the most essential element of progress.

Edited December 27, 2012 by Jaymazing

[Julian A]

I feel like the health of the patient should have priority over everything else, including seniority.

[systemet]

I'm sensing a bit of hostility from Arctickat. In response,

You may be being a little sensitive. Arctic is a nice guy, has a lot of experience as a paramedic, and has likely been in similar situations many times in the past. We get a lot of people here who try and deceive us, for whatever reason.

I think this question is something that could almost benefit from being brought up in EMT school, during discussion about ethics and moral obligations.

It could, and perhaps should be talked about. The problem is that, in the current model, there's just so little time. The training is so short, and basically inadequate, and there's so much material to cover that some things have to suffer. Unfortunately, as you've just seen, the provider is often left to work things out for themselves when they hit the road. I don't want to go on a rant about educational standards, as I think it will end up hijacking your thread.

As a student, I always just assumed paramedics knew everything.

Then I think both you and your friend have just learned a very valuable lesson.

Human beings are fallible, and every level of provider makes mistakes. Unfortunately, in health care, the patients are often unaware of the mistakes that have been made, and health care providers often collude to cover up treatment errors, and rarely inform the patient when a mistake has been made. It is very hard to be the person who speaks up in this situation, but, ultimately someone has to.

I like to hope that in EMS, we are slowly moving towards an environment where we can identify errors, and report them, without having as much fear of punitive action. Obviously poor providers need to be counselled and coached, but hopefully we can identify why errors were made, and see if there's anything we can do to prevent them from happening again.

An open mind is the most essential element of progress.

I like this.

[edit: nuked some unnecessary white space].

Edited December 27, 2012 by systemet

[DwayneEMTP]

(Edit: Creating my post at the same time as systemet. Redundancies are accidental.)

I feel like the health of the patient should have priority over everything else, including seniority.

And you would be right. But in these situations, the family is horribly traumatized most often, so when working an arrest in front of the family they should be considered patients as well, assuming that you have the time and safety to consider such things.

This is a valid question from the point of view that having an argument in such a setting can forever leave the question in their minds, "Was everything that could be done to save my loved one done?" "Did they do the right things, or did they screw up?" "Why couldn't my son have gotten one of the brave, professional teams like I see on TV? Would he have lived if they'd not been arguing??" I've no interest in the legal implications of such things, but for a family that's just had the horrible image of their loved one being molested by people doing CPR forced into their brains forever, adding to that in even a tiny way is a huge deal to me and should be considered a massive failure by any team.

Jay, though I'm a big fan of you, this thread, and your participation, for me a huge part of EMS is respecting those that came before us, if they deserve it, and being grateful to our betters for taking the time and giving the attention to teach us. Both are categories that ArticKat fits into solidly where both you and I are concerned. His statement was prudent, despite you're being offended by it. I would be curious if, after rereading it, you are happy with the tone that your reply was created in? Being snippy and arrogant in the face of someone that's been a really important member of the City and EMS familes for a long time doesn't look good on you my friend....

And yeah, man, I think that this is a question that should absolutely be taught, and even practiced thoroughly, in basic/medic school.