How would you handle this?

[fire911medic]

I recently had an encounter with this. I took a patient into the ER from a motor vehicle accident (car in ditch, minimal damage to car, no airbag deployment, fairly low speed impact approx 35 mph estimate). Well, spoke with patient who had minor bruising on shoulder/chest area from seatbelt (was a restrained driver), but main complaint was from thigh pain. Pain was midshaft, no obvious deformity, but on any attempt to move, pt screamed out in pain. Leg was shortened and externally rotated, so traction was given and Sager splint applied. Patient stated relief with that. I did not give pain meds on scene as we were just a few minutes from the hospital, and also the person was an extremely difficult IV stick (0 success out of 4 attempts). When we got to the ER I gave full report to doc (mind you at a regional trauma center) and stated suspected isolated femur fracture. Pt was complaining of pain of 8 out of 10. We left assuming the pt would get pain meds, x-rays, and taken good care of as most people we bring in are. Approximately 2 hours later, we returned with a different patient, and decided to check up on the previous patient. Still in the ER, crying in pain, no x-rays, nauseous from pain, and still on a backboard. ER only had four patients in it, so no excuse. Spoke with doc as to the reason no pain medication was given, and he stated he didn't think it was neccessary. That our patient was probably a drug seeker just looking for meds (pt was local and had not been transported for chronic pain by us and not on any pain meds daily). I got angry, but unfortunately no longer my patient, I expressed my concern to the doc who completely dismissed me. He stated he'd give her some motrin before she left if she felt she was still in pain. Today I filed a complaint with the hospital, as I feel no patient, especially one with a suspected femur fracture and in traction should be forced to stay in pain for several hours. I am still waiting to hear back regarding that, but I feel the doc's care and attitude should definitely be examined by the hospital admin. What would you guys do in this situation and do you feel I took appropriate steps? Anything you would do differently? Note, an IV was never started after I stated 4 failed attempts, and no pain meds were ever given to patient prior to discharge, which I confirmed with the patient's nurse before filing the complaint. I did not speak further with the patient, but I am curious to see how you would handle this and what you would have done differently (note less than 5 min transport time, and scene time was approx 8 min total).

[Nate]

Did you notify your supervisor, generally you should do that before you speak with the hospital. Your service might have a contact (ours does) with in the hospital that handles issues that might be sensitive (such as this one) between the staff and EMS.

[Just Plain Ruff]

Be prepared for a battle or retribution from that doc to you. What did you file in your complaint? I'd think that you may have opened a can of worms, Docs can be pretty retaliatory when it comes people filing complaints.

Did you file it because your patient had not received pain meds or did you file it out of anger when the doc dismissed you?

What was the patient acuity like in the ER when you brought her in. Were there only 5 minor patients or were there 5 really critical or serious patients?

I'm just trying to get a idea of the circumstances.

and I definately agree with the above poster, you probably should have gone to your supervisor first prior to filing a complaint. I am not so certain you really got all the facts.

good luck in whatever happens.

[akflightmedic]

You definitely opened a can of worms by doing a write up yourself. There should be and you always should use someone from your service to present any complaint to a hospital official with regards to the care a physican gives or doesnt give. Doctors do not know all but they can make your life hell if you cross them, you should follow proper channels.

Now, to offer a different perspective on this situation. The patient was DISCHARGED with no meds. Sounds to me like there was no femur fracture. Maybe the doctor did a thorough assessment and determined there was no need for pain meds, maybe the patient was a drug seeker. Just because you have not transported them does not mean they haven't been in there seeking drugs. No xrays were done....hmmmm, the good ole days do survive in some areas...areas where a doctor can perform an assessment and not have to run a full battery of uneccessary tests to prove what he/she already knows.

Just as an outsider looking in, it seems to be you are a bit peeved that you were dismissed with no explanation. Maybe the doctor felt he did not have to answer to you. Maybe your attitude or tone set the mood from the get go. I dont know, I wasnt there but I am offering possible scenarios as an impartial observer.

Whatever the outcome, good luck to you...you are going to need it.

ps. I cant help but notice 4 failed IV attempts with an 8 min scene time and a 5 min tx time...you must be pretty damn good to try that many times and still back board, put them on a monitor, get vitals, etc....very impressive, except you missed 4 times.

[fire911medic]

I understand that I may have opened a can of worms. I don't like that possibility, however, I do want what is best for my patient, and appropriate pain control is such. We only work one medic on duty per shift which happened to be yours truly, so I was shift supervisor. Only one ahead of me in the food chain is our director, who really didn't give a care. He stated it was no longer my patient, therefore, no longer my worry. The complaint was not filed in anger in any way at the fact that I was dismissed, and truly was not filed in anger at all. I thought very carefully before filing a complaint (didn't do so until the next afternoon to give myself time to figure things out and how to go about it in an appropriate, non accusatory manner). I don't care what a doctor says or does to me, that's fine I can take it, but I refuse to see a patient treated inappropriately. I've been in this a while, and I just won't have it. The fact that I spoke with the doc to attempt to get a legitimate medical reason for not giving pain meds and his flip attitude regarding it, makes me wonder if this doc really addresses the patient's concerns or not. I can understand not wanting to give narcotics, but there are several acceptable alternatives which could have been given, and I don't understand why they were not utilized. Vitals were stable, the patient was just in pain. The ER had minor patients (your typical headache, belly pain, two nausea, and I forget what the other was, but nothing major, all were stable). I wouldn't have even started down this road except I don't like seeing a patient suffer, and if it was well within my protocols to give pain meds without med control orders, why wouldn't they? I know I could have gone the IM route with her, but due to proximity to hospital, and the assumption that she would be given some promptly (I can understand a reasonable wait if busy or simply just overloaded that night with things), I opted not to give any. My thoughts are, if this was your patient, would you stand up for them? If it was you, would you want to be the patient laying there suffering or would you want someone to speak for you? And finally do you think what this doctor did was right? I'm not trying to start a war here, but I am looking for suggestions on how to address the situation with patient advocacy as I have left them a message requesting to speak with them "regarding a patient care concern on such and such a date" which was all I stated. Nothing more, so I haven't actually addressed the situation with a person yet. Any ideas? Thanks and I appreciate your experience and input.

[MedicRN]

He stated it was no longer my patient, therefore, no longer my worry.

You answered your own question.

[akflightmedic]

PLEASE tell me the final disposition of the patient. Was there a femur fracture?

I think there may be more to the story than you are aware.

Once I turn care over to a physician, I really do not care what course of action the doctor takes. It is no longer my issue.

If I were in your shoes, I would have given IM pain meds if I felt the need was so great. As the only medic on scene, you still havent really explained to me how you could do a proper assessment, backboard, vitals, ALS the patient and do 4 IV attempts in such a short time frame...yes you may be good but time is not on your side in this case.

Anyways, in the future, I guess you wont withold pain meds when you feel they are justified if you think you know more than the doctor when it comes to pain control. By the way, I am a huge advocate for pain relief in the field, however there is something about this whole scenario which still smells funny to me. I will keep asking questions as you provide more details...

[Scaramedic]

"He stated he'd give her some motrin before she left if she felt she was still in pain"

Does this mean he was sending her home? Correct me if I'm wrong but you don't send femur fractures home. So did she have a femur fracture or not? If she did not I would seriously question your diagnostic abilities. Also if no femur fracture then the sager was a bit of overkill was it not? Please answer these questions before I can tell if you were out of line or not.

Peace,

Marty

:joker:

[fire911medic]

Final Disposition : Home with no femur fracture, was given scrip for pain meds to go home with (Lortab) so pain concern was addressed after discharge, just not during ER stay, which was my main concern.

As far as the comment as to proper assessment and things, we have three on a truck usually. A medic student, medic and a basic, in addition to the rescue squad which had been dispatched, and pretty well had the patient ready to go for us when we arrived. All we had to do was board her and get her up in the truck. The attempts and care was divided between myself and the student. The student also expressed concerns with the care, but accepted the doc's refusal to give pain meds.

Regarding the following up with the patient, that is not unusual for me. If we are fairly slow, as is the ER, I'll check back up on patients later to see how they are doing, and see what the findings were. I use that as a learning experience for myself, as this will be as well. I am not looking to crucify a doc, I simply want to discuss a patient care concern and see what his insight was further on it as I am not an MD and do not have his wealth of knowledge (nor do I even remotely claim to). This doc is typically very good about educating us, and did so excellently in cardiac when I was in class, so I have respect for him. I am not looking to start a pissing contest, I want to address this with grace and tact, more of a discussion rather than an actual complaint. I guess I should have clarified that better.

As far as why did I apply this Sager? Well, indications aside from instability were there. There was shortening, rotation, pain midshaft, worse with movement, which was relieved when traction was applied, and bruising and edema were present. Do I think I was out of line applying the splint? No I don't. Last time I checked, that was all the indications short of deformity for a femur fracture, and I have seen femur fractures without frank deformity in well muscled or extremely heavy individuals (the person was fairly well muscled), so they provided splinting in itself.

I know I have alot to learn, that's why I love this job, and like i said, I'm not here to start a pissing contest, I was asking for indications to why doc may not have given meds and how to address the situation with grace and tact with them to avoid any resentment.

[ALERT Medic]

Does this mean he was sending her home? Correct me if I'm wrong but you don't send femur fractures home. So did she have a femur fracture or not? If she did not I would seriously question your diagnostic abilities. Also if no femur fracture then the sager was a bit of overkill was it not? Please answer these questions before I can tell if you were out of line or not.

Peace,

Marty

:joker:

Actually, according to his original post, I think he was justified in applying a traction splint. He believed that the posibility of a mid shaft femur fracture was present and better to err on the side of the patient and cover you own ass and just apply the splint. Anyway, the original question was how we would handle the situation about the doc. And you're right, femur fractures don't get sent home but he also said that no x-rays had been taken at that point. I don't feel like he got the whole story but from a patient care point, he did the right thing. Femur fractures are serious and require surgery to repair. He recognized the great potential for a femur fracture and treated accordingly.

I agree with everyone else that a can of worms was opened and he should have spoken with his supervisor first. Follow a chain of command. It is our policy that anytime we have an issue with allied health care personnel, we make a report in writing to our supervisor and see what happens. Usually it's taken care of from there.