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Yes... yet ANOTHER Death Determination FAIL


Dustdevil

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Looks like San Antonio firemonkeys have figured out the easy way to get out of ambulance duty for the remainder of their career. :thumbsdown:

http://www.firerescue1.com/fire-ems/articles/733194-Care-of-San-Antonio-accident-victim-probed/


  • Care of San Antonio accident victim probed

    By Eva Ruth Moravec
    The San Antonio Express-News

    SAN ANTONIO — San Antonio Fire Department officials are reviewing whether emergency personnel responding to a traffic accident last week presumed a pedestrian was dead before they discovered she had a faint pulse.

    "The incident is being reviewed right now to make sure the proper procedures were followed," department spokeswoman Melissa Sparks said about Friday's accident. "It's too early in the investigation to determine exactly what happened."

    It wasn't immediately clear if paramedics checked vital signs upon arrival, as prescribed in the Fire Department's standard operating procedures.

    Last year, paramedics were disciplined after an investigation of a 2007 accident showed that a crash victim was mistakenly presumed dead and died the next day.

    On Friday, Alicia Trinidad, 56, was struck by a Ford pickup driven by Ruben Rojas, 37, just after 5 p.m. as she walked across Gillette Boulevard toting freshly made tamales she planned to sell. A San Antonio Police Department report states Rojas failed to yield right of way to Trinidad, who used a crosswalk at Moursund and Gillette boulevards. Rojas has not been charged.

    Trinidad had just left her oldest daughter's home in the 300 block of Gillette, where she lived with her daughter and son-in-law and their four children. She frequently walked to the intersection to catch a bus, said daughter Cindy Trinidad, 35, who came upon the crash on her way to pick up her husband from work.

    "About five minutes after she left, I drove down the street and saw the commotion," she said. "I saw the blue bag that she was carrying on the ground, and immediately, I knew it was her."

    She said that when she got to the scene, someone approached and told her it was too late. Her mother was lying on the pavement in the intersection with severe head trauma.

    "I began hysterically crying, and they covered her with a yellow tarp," Cindy Trinidad said. "Then, a few minutes later, someone told me they found a pulse and they uncovered her."

    A spokesman for the San Antonio Professional Firefighters Association said the union is aware of the incident and is conducting its own investigation.

    According to the police report, Alicia Trinidad was flown to University Hospital at 5:15 p.m. Less than an hour later, a doctor pronounced her dead.

    "Are there questions in this situation? Yes, there may be some. We'll never know what might have happened," Cindy Trinidad said.

    In December 2007, a paramedic concluded that Erica Nicole Smith, 23, was dead at the scene of a head-on collision. She was left in the crashed car and covered with a yellow tarp for more than an hour before a medical examiner at the scene noticed she was breathing. Smith was hospitalized and died the next day.

    City Attorney Michael Bernard later said that checking for vital signs, which the paramedic failed to do in Smith's case, is part of the Fire Department's protocol.

    While officials investigate what happened Friday, the Trinidads are wondering how they will cope with their first Christmas without their mother and grandmother.

    "That night, we made tamales to sell, but our tradition is to make tamales for the family on Christmas Day," Cindy Trinidad said.

    "She (Alicia Trinidad) would always head that up, and she left without giving me the recipe."

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Your comment about having the firemonkeys get out of ambulance duty may be true in some places. Around here, for any FF hired for the last 15 years, their EMTB license is a condition of employment, so if they screw up medically, they are out of a job. Problem is, they are never caught and/or disciplined for medical mistakes, although they do happen. Same with drivers licenses, so a DUI could cost you your job.

When unions are involved, these things gets dicey. Someone can grieve the discipline, and it's usually reduced to a heavy suspension rather than a termination.

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In my neck of the woods, we do not request a pronouncement unless we get asystole in 3 leads. I don't understand why this is not a standard everywhere, seeing as it's too much to ask that emergency health providers understand non-perfusing beats.

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When I lived in Toronto, A deejay on Q107 used to have a feature called the "Tool of the Day". These clowns would qualify for it.

It's not as if it was a MCI where there were multiple patient's to take care off and they had to triage the scene. There was one. Check for V/S, place the pt. in your ambulance and do your freakin' job! Just because there was major head trauma (which is criteria here for pronouncement) doesn't mean you don't assess! This shyte makes my blood boil and I am getting really tired of reading articles about piss poor pt. care. If you don't want to do it, fine. Don't let the door hit you in the ass on the way out of my profession.

I also noticed that the driver had not been charged at the time of the articles writing. However, the article clearly states that the driver of the pickup "failed to yield" the right of way. WTF?

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Going back to the 17th, 18th, 19th Centuries.. They would affix a cord in coffins, attached to a bell, in case the dead woke up. Are these folks ancestors of those who made a habit of burying people alive? If that were me, in their shoes, I don't think I'd be able to handle that. If I left someone, then they were found alive, I'd prolly have to be sedated, or locked in a rubber room. Every one of these stories just screams "WHAT THE FUCK IS WRONG WITH YOU!?!?!"

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I also noticed that the driver had not been charged at the time of the articles writing. However, the article clearly states that the driver of the pickup "failed to yield" the right of way. WTF?

Could it be they are also continuing their investigation to determine if additional charges will be filed? The muck up by the Paramedics could change whether it is vehicular manslaughter or whatever if the autopsy's proves her injuries were not survivable regardless of the Paramedics' failure to determine death.

As far as declaring death, there are reasons why the AHA has de-emphasized checking for a carotid pulse. Even for health care practitioners, it might be difficult to palpate and especially when one has become dependent on technology. How many times to do Paramedics palpate pulses? They have the pulse oximeter, automated BP monitor and the cardiac monitor to tell them HR. Why would one need to actually touch a patient beyond placing one of these devices? How many times a month would they even work a code? Or, how many times have they physically checked pulses when CPR is being performed? Many times they may just attach the pads and let it do the work for them.

I also learned recently while teaching NRP to a group of Paramedics that they are not taught listening to heart sounds of any type including the apical heart beat even on an infant or child.

Some should also spend more time in an ICU assessing critically ill patients. They will find that we keep a doppler around because sick patients just don't have obvious pulses. We also have a whole know generation of post ECMO "kids" that are now adults. Finding a carotid on them might prove difficult at best. Then we have the adults who have been on ECMO for H1N1 which may present a challenge depending on where the cannulation was.

Even after many years of palpating pulses I still have to remove a glove, provided there are no messy sustances and then I might just clean off, to find the pulse. I also had to unlearn all that 70, 80, 90 stuff for BP that I learned in Paramedic school or part of the "street smarts" when I noticed that I occasionally got a radial pulse at a BP of 70 confirmed by A-line and cuff as well as having no pulse with a BP of 140 systolic.

This is just another incident that happened to make headlines because the patient was left in the field. EDs across the country have their own horror stories about Paramedics who fail to recognize life threatening situations or notice their patients are dead. Not knowing what agonal breathing is one of my personal favorites. Not recognizing it because the patient's RR is "text book normal" of 12 is almost laughable if it was not so tragic for the patient. The other is when a CCT with a couple of "CCEMT-Ps" don't believe the asystole on their cardiac monitor because the ventilator hadn't alarmed "apnea" while set on a rate of 12. Yeah the LTV 1200 is a little too much machine for them like giving a Porsche to someone who still has training wheels on their bicycle and telling them it is idiot proof and practically drives by itself.

Your comment about having the firemonkeys get out of ambulance duty may be true in some places. Around here, for any FF hired for the last 15 years, their EMTB license is a condition of employment, so if they screw up medically, they are out of a job.

Many of our FDs want a Paramedic cert at time of hire or within one year of hire. Thus, no time for a proper education and a PDQ medic mill will have to do. For some, once you have served on the ambulance or lead on an ALS engine/ladder you might move to a position that requires little to no patient contact but may still maintain you Paramedic cert for extra pay. After a few years that requirement may be dropped if your position is on that requires no patient contact. Florida also has the option for the Paramedic to drop to EMT-B status for FFs to still maintain minimal standards or if they screw up bad enough to have their Paramedic license removed they can still be an EMT-B.

Edited by VentMedic
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Could it be they are also continuing their investigation to determine if additional charges will be filed? The muck up by the Paramedics could change whether it is vehicular manslaughter or whatever if the autopsy's proves her injuries were not survivable regardless of the Paramedics' failure to determine death.

As far as declaring death, there are reasons why the AHA has de-emphasized checking for a carotid pulse. Even for health care practitioners, it might be difficult to palpate and especially when one has become dependent on technology. How many times to do Paramedics palpate pulses? They have the pulse oximeter, automated BP monitor and the cardiac monitor to tell them HR. Why would one need to actually touch a patient beyond placing one of these devices? How many times a month would they even work a code? Or, how many times have they physically checked pulses when CPR is being performed? Many times they may just attach the pads and let it do the work for them.

I also learned recently while teaching NRP to a group of Paramedics that they are not taught listening to heart sounds of any type including the apical heart beat even on an infant or child.

Some should also spend more time in an ICU assessing critically ill patients. They will find that we keep a doppler around because sick patients just don't have obvious pulses. We also have a whole know generation of post ECMO "kids" that are now adults. Finding a carotid on them might prove difficult at best. Then we have the adults who have been on ECMO for H1N1 which may present a challenge depending on where the cannulation was.

Even after many years of palpating pulses I still have to remove a glove, provided there are no messy sustances and then I might just clean off, to find the pulse. I also had to unlearn all that 70, 80, 90 stuff for BP that I learned in Paramedic school or part of the "street smarts" when I noticed that I occasionally got a radial pulse at a BP of 70 confirmed by A-line and cuff as well as having no pulse with a BP of 140 systolic.

This is just another incident that happened to make headlines because the patient was left in the field. EDs across the country have their own horror stories about Paramedics who fail to recognize life threatening situations or notice their patients are dead. Not knowing what agonal breathing is one of my personal favorites. Not recognizing it because the patient's RR is "text book normal" of 12 is almost laughable if it was not so tragic for the patient. The other is when a CCT with a couple of "CCEMT-Ps" don't believe the asystole on their cardiac monitor because the ventilator hadn't alarmed "apnea" while set on a rate of 12. Yeah the LTV 1200 is a little too much machine for them like giving a Porsche to someone who still has training wheels on their bicycle and telling them it is idiot proof and practically drives by itself.

Many of our FDs want a Paramedic cert at time of hire or within one year of hire. Thus, no time for a proper education and a PDQ medic mill will have to do. For some, once you have served on the ambulance or lead on an ALS engine/ladder you might move to a position that requires little to no patient contact but may still maintain you Paramedic cert for extra pay. After a few years that requirement may be dropped if your position is on that requires no patient contact. Florida also has the option for the Paramedic to drop to EMT-B status for FFs to still maintain minimal standards or if they screw up bad enough to have their Paramedic license removed they can still be an EMT-B.

Interesting comment about the palpating pulses so the person must have a systolic BP of 70, 80, or 90, etc. It took awhile for me to learn that patients don't usually read our textbooks and if they CAN present in an unusual or nonstandard fashion, they WILL. I had to tell my students that a "rule of thumb" is highly dependent on the size of one's thumb. That always caused them to scratch their heads, but eventually they got it.

As for mandating a paramedic level for FF's, it will never happen here. It is talked about occasionally, but the racial implications were staggering. I know many places that either require a paramedic license BEFORE you get hired as a FF, or as you said, within a year or 2 of hire, but not here. They can't even require EMTB as a prerequisite for the job because they cannot get the proper ratio of minorities with only a simple 6th grade level entrance exam. Requiring an EMTB license would be devastating to those numbers. Wrong- sure, but that's the political reality.

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As for mandating a paramedic level for FF's, it will never happen here. It is talked about occasionally, but the racial implications were staggering. I know many places that either require a paramedic license BEFORE you get hired as a FF, or as you said, within a year or 2 of hire, but not here. They can't even require EMTB as a prerequisite for the job because they cannot get the proper ratio of minorities with only a simple 6th grade level entrance exam. Requiring an EMTB license would be devastating to those numbers. Wrong- sure, but that's the political reality.

For the 2 states I am most familiar with, Florida and California, the white all American born male has the most problem with passing the EMT-B. In Florida we have a large European and Cuban population where the elementary schools out perform most American high schools so getting an EMT-P is not a problem especially with the 10th grade text book. Thus, it is difficult to find all white American born applicants to make the score when the competition at 8th grade is academically higher than some of our college freshmen. Also those from other countries speak at least two and usually three different languages fluently which makes them an asset to any employer.

Of course, Oakland, CA FD did drop their EMT-B requirement and got well over 10,000 applications for 20 openings and actually had a difficult time picking out qualified individuals to fill those positions.

Edited by VentMedic
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As far as declaring death, there are reasons why the AHA has de-emphasized checking for a carotid pulse. Even for health care practitioners, it might be difficult to palpate and especially when one has become dependent on technology. How many times to do Paramedics palpate pulses? They have the pulse oximeter, automated BP monitor and the cardiac monitor to tell them HR. Why would one need to actually touch a patient beyond placing one of these devices? How many times a month would they even work a code? Or, how many times have they physically checked pulses when CPR is being performed? Many times they may just attach the pads and let it do the work for them.

No pulse checks? I’m not accusing you personally but damn. I palpate either a radial or carotid pulse on every patient for several reasons (no, not every patient I’ve had actually has a pulse). Number one it prevents me from losing the skill. Number two it actually gives me an idea as to whether or not my more automated equipment can be trusted. Pulse rates determined by a pulse oximeter are useless if a patient has an irregular rhythm. Automated BP cuffs are also unreliable with an irregular pulse. My first BP on every scene call is manually auscultated. Even many of our ALS providers continue to go manual on the first BP.

This whole issue brings to mind a patient from one of my hospital clinical days. This man would experience periodic runs of bigeminal PVC’s as shown by the monitor in lead II. The man’s heart rate as calculated by the monitor was 60 BPM yet he would turn grey and feel weak during these episodes. I tried taking a manual rate by palpation out of curiosity (we were allowed to work with patients but were not specifically responsible for ensuring care). I learned the damndest thing. His “PVC’s” had no mechanical capture whatsoever. His actual pulse rate during said episodes was 30BPM crashing his perfusion whenever it occurred. Monitors, pulse oximiters etc. are all great tools. They do not however, replace what can be learned by taking the time to actually look, listen, and feel. Whenever I read about this type of incident it angers me. Primarily it angers me because it is the direct result of complacency.

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