mffrhorne

The patient believed that she was being transported to her death.  With proper hospice counseling she need not have been subjected to that additional dose of fear.  Even if it was not possible to care for her at home she would have known what to expect and transport need not have been as terrifying as it ended up being for her. 

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Tom

It was some years back but I went through several similar calls and in each case we did not transport.  The only time I ever transported a patient against her will was a Cancer Pt who was to be taken from home to hospital and everyone but the patient wanted her to go including the doctor who had arranged for the transport.  It was the patients failure to answer the A&O X 3 questions that decided the outcome.  I still wish her family could have born up under the stress of having her die at home.  If they had only had good hospice counseling we might have avoided putting the patient through the fear of "going to die."

 

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Tom

I agree with those who suggest that you can ethically take this person against his will, as being a threat to himself. In fact, I have in the past, contacted my resource hospital for their orders to do just exactly that in a medical run. The person was clearly in need of medical care, was anwering all questions clearly and correctly, yet was refusing transport. I contacted the resource hospital, either to document the refusal or better yet to get the order to transport against the subjects will. The ER Dr. agreed with my assessment that this person required medical care, and that refusal to seek it was tantamount to having an altered mental status and made the PT a threat to themself.

Of course, other systems rules and policies may, and probably will, vary.

Legal issues aside I would not like to force him to accept care. Without going back on what I just said I would think that a conscientious application of "Danger to himself or others" would only apply to his ongoing voluntary actions rather than to a apparently cogent refusal of care.

Now I turn the legal issues back on. I would continue or start the back up medic unit since I am an EMT-B. I would get a radio consult, request orders, and ask for a go team. I would request a peace officer to the scene to witness an extreme refusal against medical advice.

Given the law in my state I would ask for a police transport of an adult protective services officer on a life or death basis. I am fairly sure I would get that but that protective officer would be on a "white knuckle express" and fairly rattled by the time they reached the scene. I will not pretend to understand the law under which the adult protective people operate but I do know that they can force someone to accept medical care or shelter. They most often deal with the homeless. They are not peace officers in the traditional sense but rather seem to function as officers of the courts. I have only seen them at work once myself that I recall and they spent time on the phone talking to a court clerk who MAY have been relaying things to a judge. Once they got what they needed they ordered the police to assist in the removal of the patient to appropriate care and the police officers seemed quite confident in obeying their orders. I think that it is important to say that my patient in that incident was so badly frost bitten that his feet were black so that is a quite different set of circumstances than a traumatic injury. By the time the patient was transported I had a medic unit, EMS duty officer, three LEOs, and the adult protective services officer on scene.

I don't know if that would work in the case under discussion but I would try it.

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Tom Horne

Hello, Everyone.

As always, these "news-blasts" are sent "blind carbon copy" for privacy

concerns, and apologize for inadvertent multiple sends to multiple

e-mail addresses.

As of noon, 11-13-2012, the updates are as follows...

Snip

My girlfriend and I continue the shuttle, every few days, between our

houses in Belle Harbor, from the motel in Montgomery, NY, to check on

ongoing repairs, and pull our mail from the mailboxes. Still under

presumption the Breaker-box will need total rewiring due to salt water

immersion, before we can power up and run the (hopefully) repaired

furnace and hot water boiler (or more likely replaced units).

Snip

Good luck to us all!

Richard B.

Richard

If the governer of New York does decide to allow out of area electricians to work in the releif effort let me know and I will make your house my objective. I am an electrician by craft and a volunteer firefighter rescuer by avocation. I would be happy to help you do any rewiring that is required. I have the equipment needed to test your surviving wiring for any problems and identify what needs replacing without pulling out everything in the house. Just let me know what is will work for you and I will be there.

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Tom Horne

I just have to ask now that Richard B has brought it up. Is there such a thing as a NIBP that does work in a moving unit?

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Tom

I don't see any easy solution to the equipment pilferage problem. The hospitals here had a closet with an exterior door. It used to be everything was thrown in together. More recently some of the hospitals have moved the retrieval area inside and separated it by service. If you are from one county you can only get the key for that counties storage closet. An adjacent county that we work with a lot is terribly underfunded by their county council. Their staff cannot get enough equipment to take care of their patients so they misappropriate ours. I had gone to retrieve equipment from a hospital in this adjacent county and found one of their crews loading two of our backboard sets into their unit. I told them I was there to retrieve the equipment and I wanted it surrendered right then. They acted like I was the one being an A-hole. I finally lost my temper and told them I would be on the radio to our EMS duty officer if they did not surrender the equipment. They tried to act unconcerned so I used the radio. The EMS duty officer was busy directing operations at a multiple vehicle collision. He told me to turn on the outside speaker on the utility truck I was driving and then he gave me a direct order to summon the State Police if the equipment was not surrendered. The State Police here must respond when called even if the area in question has a local police force. He then told me that if they left prior to the arrival of the Sate Police I was to go the county commissioner's office to swear out a warrant. I assume that last was for dramatic affect because I knew I did not have the authority to swear out a warrant on behalf of my county. His tactic worked and the equipment was turned over to me but I concerned that crew and likely a lot of their coworkers would be looking for payback because I had lost my temper and embarrassed them. There were some hard looks on later calls but it never came to more than that. Their dispatchers monitor out radio nets and vice versa. They must have gotten their supervisors involved because several senior officers were in a meeting between the two counties before the day was out even though the incident happened around 3:00 and the senior officers normally go home at 4:30. The problem then diminished for a time but of course it came back gradually to it's old level. The separate locker thing helps but some of the equipment gets pilfered while it is waiting to be taken to the locker. This happens when the boards or splints are standing against the wall outside of X ray for instance these being extremely busy hospitals. It has been suggested that hospital security should review the security video when equipment goes missing but anyone who thinks about that idea knows that they don't have the time I don't have any good answer. I suppose that is what EMS duty officers are for but they cannot produce miracles.

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Tom

An equipment audit at a major US airport revealed that there were six spare AEDs in the training locker and the training AEDs were missing. The mystery was solved when a check of the purchasing records revealed that the airport did not own any spare AEDs.

An Airport laborer had been ordered to stock all of the AEDs in the cabinets along the concourse of a renovated terminal and had placed the training AEDs in some of the cabinets. So who says bean counters only cause trouble?

My take home from this is that training AEDs should never be in the same storage location as the real ones. Positioning of public use AEDs should be done by responders and not untrained laborers. Newly installed AEDs should be checked immediately after installation by someone other than the installer.

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Tom H

Maryland is using Kaplan continuing education for their on line re certification training and after having used it for the first time this cycle I am favorably impressed. The question is would a year long subscription to their service be worth the one hundred twenty dollar cost. I would especially like to hear from anyone who has actually had the use of the annual service with what your experience was.

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Tom Horne

Many years ago I ran an ambulance call for an injured child and was advised on route that a baby was being shaken out a window and police were en route. The policy that we follow today of staying out of insecure violent incidents was not in place back then and the actions you took were at your discretion. We continued into the scene and dispatch told us that the baby was being used to extort money from the mother. On arrival we saw that a baby was indeed being waved out a window by his feet three stories in the air. As we ran up the stairs my partner said "If you can distract the guy for just a minute I can get the baby." I was terrified that the baby would fall to his death and shaking with anger at the same time. A crying child opened the door and said "He's hurting my brother." I entered the living room and spoke as calmly as I could manage. The assailant looked at me with wild eyes and said "Don't touch me cop or I smash the brat." I realized that he had mistaken my fire service uniform for that of the police. I said "I'm a firefighter. I only want to check the baby." Suddenly a pair of hands appeared and grabbed the child. In the adjacent kitchen my driver had gone out the window and reached across to grab the child without belay or back up three stories in the air. The perpetrator (perp). looked at his now empty hand and then charged me intent on the impulse to escape. I swung the Oxygen set at his head and I thank God I missed. The tank busted a large hole in the metal lath and plaster wall. Having ducked under the blow the assailant fled. I took a ragged breath and looked around at one of the bleaker rooms I had ever seen. One bare light bulb, broken furniture, an empty drawer in use as a crib made up most of the rooms contents. My partner came in from the adjacent kitchen holding a baby very close to him saying over and over "He's all right. He's all right."

We executed the protocol for a shaken baby, gathered up mother and two other children and started down the stairs to great an Army of police officers from four different agencies. We loaded the family while the Law Enforcement Officers (LEOs) got a description of the perp. from us. It was the only truly complete description I had ever given of anyone. Working from the picture of the madman that was etched into my brain I described him from the hair on his head to the salt stains on his shoes. After transporting the entire family to children's hospital we transported the assailant that the LEOs had caught up with some distance away. He had put up a fight and two officers had the bruises to prove it but they had subdued him and we took him in for stitches. Upon return to quarters the incident caught up with me and I went into the hose tower and screamed.

The firefighter who had been one of my EMT evaluators took and sat me down and made me tell him about every detail of the incident that I had seen. When I was finally done he said "You can't fix the world but you can mend parts of it. He got the shift together and said "we have a family to care for." "Are you out of your mind? It's Christmas eve! Most of the stores are closed." the shift chorused. The captain spoke up and said "I think this shift could pull it off on Christmas day." No one argued any further. The Ambulance went to the grocery, the truck to the Toy's R Us, the engine to a child care supply store. Between the three units we assembled a Christmas for a family that had nothing and needed everything. The last item was the only Christmas tree that had not been bought at the departments tree sale fund raiser. The crew shortened that pore scraggly thing at both ends and trimmed it to a decent shape. A raid on an 24 hour pharmacy scored lights and ornaments. We called the hospital and found they would not be done with the baby for several more hours. The family would be sent home in a taxi in the morning. It was eleven PM before we were completely ready and by now the guys were really into it. We arrived back at the apartment building, laddered the apartment, and hauled all the supplies up the aerial since the apartment door had a double cylinder Detroit jimmy proof lock. The only problem was a drunken neighbor who demanded to know why they were getting the special service. I looked him dead in the eye and said "the regulations say I don't have to answer questions from drunks." He seemed to accept that and walked away. Two different LEOs came buy with a few more things and we all agreed that at least for one day the baby's brother and sister and yes even his mom could believe in Santa Claus.

Some of you may have read my account of this incident before. But every Christmas it comes back to me very strongly and I feel the need to share it again.

Take care of each other and know that God loves you even though the only instruments he has to express that love is the actions of decent human beings just like you.

--

Firefighter / Rescuer Thomas D. Horne speaking for himself and not the

Takoma Park Volunteer Fire Department an assisting agency of the

Montgomery County Fire and Rescue Service, Maryland, USA

Well, we aren't no thin blue heroes and yet we aren't no blackguards to

Just working men and women most remarkable like you.

You may have a 'duty to act' for the call you're heading to, but while enroute; you have a 'duty to act safely and responsibly'!

Most motor vehicle codes will allow certain 'acts' to be done while driving with lights flashing and sirens blaring, but only while 'driving with due regard to public safety' and safe operations of the motor vehicle you're piloting.

This is where the 'dead horse' thing comes in...

Most people tend to 'overvalue' their driving skills. Combine that with the misconception that lights and sirens are a GUARANTEE of right of way, and you've got a disaster just looking for a place to happen.

Unfortunately, the biggest group of people that suffer from this affliction are the newer people. Unfortunately, us 'old dogs' can't seem to get through to them, because we can't get past the "it'll never happen to me" mentality.

Guess what??? it CAN happen to YOU! Unless you (directed at those that suffer from this affliction)change your ways, it WILL happen to you!

If you "can't really stop", then you're going way too fast to be operating that ambulance in a safe manner, and exercising 'due regard' for the public safety.

Just because someone called 9-1-1, doesn't mean that we have to succumb to the 'balls to the wall' response mentality. You're not 'saving time' by driving 90 mph, and if you crack up the truck....well you're going to be NO GOOD to the patient that called......

It's THEIR 'emergency', and they need you to respond in a safe manner. The rescuer that needs to be rescued is of no value to anyone!

Lonestar

You nailed it Sir. It is indeed their emergency. Tell me how to get that one idea through to the newer folks and you will have been a tremendous help. If we are not having an emergency then there is no reason to act like we are. I still remember how some of the Old Hands seemed so blase' about emergency responses. Fortunately they were patient with me and I learned why. Some even took the time to refer me to the available analysis of how little we actually saved when running with the warning devices operating. I was really surprised at how little time was gained. Your useless if you don't get there. Would the few minutes you might have saved by taking additional risks make a difference. I cannot remember one case were the answer was yes in thirty seven years of service.

Is there a place in EMS for Dash cameras and tamper resistant recorders. If we new that every time we violated policy that we would be disciplined would that stop the carnage?

I have to say that the title of this post is unfortunate. Anyone who thinks that there are fewer problems of this kind in separate service ambulance units is living in a dream world. I've worked in both and seen it first hand.

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Tom Horne

In Pennsylvania L&S is at the crew's discretion when responding to a scene, but during transport it is up to the ALS provider. No ALS provider on board? Not en route to rendezvous with an ALS provider? NO L&S!!

That is a fascinating idea. No ALS = No L&S. I like it and I'm an EMT Basic. If the patient is stable enough for transport by an EMT-B crew then aren't they stable enough for no L&S. Mind you I have the blessing of almost always having EMT-Ps available at the scene and of course that makes a difference.

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Tom Horne

Interesting enough doc......the photo remains!

Reading some of the replies on this thread makes me wonder when you have time to "snap a picture" in a critical situation? I'm not calling anyone out on this because I understand that there may be or just is a need to "prove" to the ER staff how bad things were on a scene. I just don't understand when the time is taken in those cases to stop pt care to take that photo. Even with cell phones, you have to maneuver through your menu to get to the camera. Like I said I understand the argument about using the photo for documentation, but this leads me to ask those who are thrill seeking to prove their worth online......Is it worth it to your pt that you stop working on them, so your ego can be stroked?

Leaving the internet out of this for just a minute. If I'm on a wreck job, and the patient care is under control, taking mechanism photographs with the units Polaroid may be the best contribution I can make at that time. We have the real blessing of having a lot of skilled help in a really short time on most of our incidents. Nice thing about Polaroids is that they are at least a little harder to convey electronically. Since you would have to work at it to do it most of the malintentioned types won't bother. The Polaroids end up in the patients medical file were they belong.

The doctors at our trauma center always seem grateful to have them. Once I open a ten pack I use it up so I take pictures of the riding position for that patient, passenger compartment intrusion, and exterior damage shots of both vehicles or whatever else the patients vehicle struck. One of my pictures of a shattered full sized utility pole saved a patients life according to the trauma docs. They told me that the pictures caused them to look a little further than they otherwise might have and found an inter cranial bleed. I don't think they would say that just to glad hand me so I think it can be worth doing no matter what camera you have to use.

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Tom Horne

Agreed on the chemistry recommendation. The first week or so of A&P is the goddamn Krebs Cycle, and other molecular processes that will leave you scratching your head if you don't understand basic chemical structure.

So which chemistry course? Inorganic, organic, or something that is aimed at biochemistry?

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Tom Horne

I do not know if it is still true but at one time having a drivers license in Vermont imposed a duty to stop and render assistance to the best of your ability if you were the first uninvolved driver to find the wreck. That information is decades old and I can only hope that the state has changed it's rules to some more common sense approach.

I do stop if it is safe to do so but I would not have stopped at the roadside under the conditions that existed in this incident. I also have a very strong advantage in that my work vehicle is equipped with a road hazard beacon, an arrow board, and five of the thirty six inch traffic cones with the double reflective stripes. That equipment is required for electricians who work adjacent to class three (high speed) roadways. I still will not stop if I cannot position out of the travel lanes. If I can, then I do what I can, with a regular jump bag, that is provided by my fire department. It is often true that the most I can do is to try to prevent a second accident. I do not carry step chocks or immobilization equipment so I have no business entering a car unless someone is in extremis and there is some effective intervention I can perform. My concern about entering the car is that at over two hundred pounds and six feet three inches in height I'm bound to cause some motion in any light vehicle I enter. In keeping with first of all do no harm preventing a second collision is often all that I can effectively achieve.

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Tom Horne

I'm an electrician by craft and a fire fighter EMT by avocation.

--

Tom

First off, the county medical director has stated several times that patients should be transported to their home hospital if it isn't too far out of the way (it was not in this case) and they were stable enough for the extra transport time (which, since they essentially refused to transport, this is a pretty good bet). The patient would have been transported by a private service anyways (most cities only provide ALS through the fire department and contact with a private company to provide the actual transport.).

Second, I could care less about so called job security for an interfacility transport company. If job security means screwing over patients, then sorry, I don't have the stomach for it. If job security means "don't do anything that makes SNFs mad, including calling medics and/or rerouting" like stories I've heard from other places, then sorry, I'm out. My values aren't for sale at 10/hr. If that means I lose business because the medics want to transfer my patient to the contracted company's gurney, then so be it [actual event] because I see no sense in getting into a fight on scene and delaying the patient's transport. Besides, I don't remember the last time I saw "County Medical Director" on a ballot.

Does your medical director appoint his/herself or is he/she in fact a part of management. Why do we all assume that our situation is the same as everyone else's. You are adding facts not revealed in your first post. It's easy to sandbag anyone who's views you don't like but much like burning number one fuel oil you will generate far more heat then you do light.

You seem to be jumping to a conclusion about exactly who JP is criticising.

I thought that using the language "You seem to be" was sufficient to indicate that I thought his post could be read as criticism of the fire department in question.

And you also seem to be misspelling the word "their."

He who lives by the spell check will be embarrassed by the spell check. In my dictionary the word is spelled "criticizing".

What is an "MFF/R"?

MFF/R = Master Fire Fighter / Rescuer. Some FDs call that position "Lead Fire Fighter" others "Fire Apparatus Engineer", still others call it "Chauffeur," and there is squad boss, crew chief and so on.

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Tom Horne

As I indicated in my previous reply to an individuals post ten minutes additional transport time on a priority three patient is our magic number as well. To be clear that means we may transport to a more distant facility if it will not lengthen the transport time by more then ten minutes. What complicates that is that we respond mutual aid to an adjacent city that shall remain nameless because it is the capitol of an allegedly friendly nation. That cities policy is that their EMS units will transport to any hospital in the city that the patient wants to go to. They will not transport out of the city for anything short of a working code. If you are shot on "boundary" Avenue only five minutes from a trauma center you will be transported the twenty minutes to a trauma center in the city. The totally dependent portion of that cities population; every city has some folks that are totally dependent on government services; are used to the cities policies and have learned to manipulate them to their advantage.

In the middle of a major snow storm with six inches on the pavement and more coming down my unit is dispatched mutual aid to a transit station just across the cities boundary. We arrive to find an agitated adult female who is demanding to be taken clean across the city to a hospital that is literally situated on the city boundary on the other side of that burg. The trains are suffering major delays due to icing on the surface portion of the rial lines. The ambulance is chained up on it's rear tires because the installed on spot chains do not work in snow that deep. I explain that we can only take her to the closest hospital. She says I want to go to X hospital and you have to take me.

Since the transport station in question is an elevated above ground station I point out our unit in the parking lot below and ask the patient if she can read the name on the unit. She does. I say "That's not a city ambulance is it?" She says then call for a city ambulance I have to go to X hospital. I explain that if a city ambulance had been available we would not have been sent. A transit police officer steps forward and tells her that she can decline service or go with us to a hospital about one mile away for treatment. He also tells her that if she declines service and calls again she will be arrested for false emergency alarm. She sits down on the concrete bench and begins crying.

If you haven't figured it out yet this woman wants a ride home. She is poorer than a church mouse. Her coat is unsuitable for the deteriorating weather. She is stuck on an elevated transit platform in a brisk wind during a snow storm. She is only one bus into a three bus and two train trip home from her mandatory welfare to work job training and the overhead speakers are warning of prolonged delays due to icing on the rails. Her child care center will charge her one dollar per minute that she is late picking up her child. We are the only resource she can think off that mite get her out of her situation. Or as Dennis Smith put it in the book "Report from Engine Company 82" "When you pull the white hook in the little red box the firefighters always show up." The only service in this woman's life that always works is the Fire Department. So when nothing else is working that's who she calls. We have the transit officer witness her refusal and return to service. Yes it is system abuse but the question is whether the system is the victim or the perp/doer.

Tom Horne, Speaking only for himself.

My views on this.

1. I am not billing. I am employed to evaluate, treat, and transport as needed. The closest I care about billing is getting the person's RN to sign the physician's certificate of necessity paper for medicare.

2. My area has at 7 well established ambulance companies, at least one up and coming company, and several other companies just outside the area that can easily find their way down here. We aren't hurting for ambulances either for interfacility or for 911 transport. Transport times are short to the hospital in most cases. In the end, it would be much easier to just transport and get it done with.

THAT SAID, I've been on one call where we transported because fire refused to let the contracted 911 BLS crew transport a patient WITH a complaint (fall secondary to dizzyness if I remember correctly) to a hospital about 10 minutes farther away than the closest hospital (that was about 5 minutes away). They were told to call a private company. That gem occured at an assisted living place [no RNs] for Alzheimer's patients.

You seem to be criticizing the fire and rescue guys for enforcing there MANAGEMENT'S policy of transporting to the closest appropriate facility. Did it escape your attention that the policy also serves as job security for you as an employee of a private provider. The body politic makes a decision through it's elected representatives to provide only emergency service, Management formulates a policy to carry out that decision, the firefighters carry out that policy by declining to provide elective transportation in violation of that policy. Sounds like a well run organization to me!

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MFF/R Tom Horne