medic001918

I've always been told, if you see an accident, and or are flagged down and you have a patient you must stop as long as your patient is not critical. Each technician will assume responsibility for one patient.

It's a very hairy situation but thats always what i was told.

Could be wrong though.

This may vary state by state, but once you're dispatched to a call you are committed to that patient and that call until it's completion. This includes arrival at the hospital. If you're on your way to a scene, you can advise dispatch you came across an accident and see if they want to reassign you. But otherwise, you have a "duty to act." Any delay that has an adverse effect on the initial patient is caused by your negligence in responding to their request for assistance. Unless dispatch reassigns you to the car accident prior to making patient contact, you need to see your call all the way to the hospital before initiating another call. What happens when you arrive to find this "critical" patient involved in a car accident and your partner is out there by himself? What if he encounters violence like in this call and you're not there to assist him? One of the golden rules for me is to never leave my partner alone in an unknown scene. Things turn quickly. But back to the critical patient, you're a legal ambulance capable of transport...except you have a patient in the back of your ambulance. This is a different scenario from an intercept medic who routinely responds alone in a vehicle not capable of patient transport. If you notify dispatch so they can send the appropriate resources to the scene of the accident you came across you have met your duty to act. By stopping, you've gone over the line and open yourself to liability with the patient you're responding to, or transporting.

Shane

NREMT-P

I can't believe some of the things that people come up. They were transporting a pediatric seizure patient and decided to stop at the scene of a car accident? And then there's people who believe that they were obligated to stop? Had the child had any negative outcome, and regardless of the medical outcome of the patient they could sue for "emotional trauma" I'm sure due to being placed in that situation while already experiencing an event themselves. To stop for an accident is negligent, regardless of the stability of the patient. I think we should all be able to agree that the appropriate thing that should have been done would be to call for an additional unit.

An ambulance that didn't have a patient on board would have been an entirely different situation however. But that's not the case here...

Shane

NREMT-P

It's not an ideal location to start an IV, but if you have no other option you can do it. I always look pretty seriously for another point of access if a victim is burned. I like to stay away from the burn site to avoid further pain to an already painful site, and also to avoid the risk of further introducing infection to the site. The two biggest problems for burn victims are fluid loss (dehydration) and infection. I try to cover the area that's burned with sterile dressings to prevent contamination. We usually have other options. Like I said, it's a last resort only to cannulate burn.

Shane

NREMT-P

What a crock of schit! To single ANYONE out based on habits, personal vices (as long as they're not illegal), sexual preference or lifestyle, and denying them the same opportunities as 'everyone else' is ILLEGAL, and is DISCRIMINATORY!

We cannot base employment on race, color, creed or religion...nor can we base housing, education or other basic rights. To single out a speciffic group of people is segregationistic and has been declared by LAW to be a 'no- no'!

There already is a precedent in place that says an employer can do exactly that. Many police department and fire departments have no smoking policies and won't entertain hiring a smoker. They must be discriminating against all the smokers illegally? Somehow, I don't think that's how it work. These are the same services that are allowed to have a physical fitness standard to get on the job, but not a requirement to maintain that level of fitness to stay on the job. To me, that sounds more discriminatory than the smoking policy. At least with that, you're not allowed to smoke when hired or at any point during your employment. And many places of employment already offer smoking cessation programs, as well as help with alcohol, weight, etc.

As far as the drinking thing goes, unless they're coming in and drinking on the job they are not taking "breaks" every so often (as frequently as every hour) to kill 5-10 minutes of paid company time. When the drinking, or coming in hung over gets to be a problem the employer has a right to terminate that employee if they want to. If they're smart, they do it under a decrease in productivity and not due to alcohol use. That will stand up much better legally.

I'm with dust on this one, I don't know as though you'll find many lawyers willing to take on that case, and even fewer courts willing to host the case.

Shane

NREMT-P

Slight problem there sparky (I'm gonna start using terms like sparky, sport, etc when people bring out the tired old cliches like "BLS before ALS," "treat the patient, not the monitor," "you lose 1 BLS skill for every ALS skill you learn [wow, doctors must be screwed by this one]," etc).

I like this rule. It applies and it made me laugh.

Otherwise, good description of pulse oximetry and why it's not the best tool for all providers to use. There have been multiple threds on pulse oximetry and the ALS and BLS provider. They've all followed the same road. Feel free to use the search function to find them and review.

Shane

NREMT-P

I'm not going in the direction of a stroke either. Built up over a few days, cushings triad (while not always present), would most likely me more prevelant and would most likely be presenting with some other associated signs and symptoms.

I'm not getting the cataract feeling. Acute glaucoma crossed my mind, but is usually a narrowing of the vision, or an encroaching darkness. That doesn't usually present with the milky description.

I want to know more about the proposed surgical procedure. What was it for? Why didn't she go? Was it secondary to injury? Was that for cataracts too? Given that she has some swelling, could it be a foreign body somehow? I know that when I used to race motorcycles I would get dirt in my eyes frequently. Sometimes it caused me to have redness, irritation, photophobia (light sensitivity) and would cause some swelling, redness and tearing. Will she allow us to have a good look at her eye, and maybe under her eyelid to look for some foreign body?

Could it also be ocular hypertension due to some sort of thrombus? Never thought I'd bring that up in a case or a sceanrio. But it seems like it could be possible. I believe ocular hypertension usually precedes full blown glaucoma...but I could be wrong.

As far as prehospital treatment, so far it sounds like BLS. Irrigate and cover the eyes, monitor vitals and transport non-emergent. I'd like to know more though...

Shane

NREMT-P

I'll echo the other's with a request for an initial assessment. Let's see what she was doing when this whole thing started? What change prompted her to call for the ambulance today? What is her medical history? Meds? Allergies? Has this ever happened to her before? Vital signs including skin color/temp? Has she ever seen her physician for something similar in the past? Any pain anywhere? While we're checking her pupils, how is her occular motor function? Can she control her eye without trouble? Or with a rull range of motion?

Shane

NREMT-P

Wait till the shoe is on the other foot and its you or your loved one that gets carried to the bad hospital and gets screwed up.I hope and pray it never happens to yall but what goes around does come around.

120 hour 1st aid course huh and you think you know whats best for someone?Good god,what idiots.

I will sue in court and win or run this ambulance service out of buisness with ads on telivision.PEOPLE DESERVE BETTER FROM SOMEONE WHO GETS PAID TO HELP THEM.

Im paying for the ride,ITS MY TAXI.

You know, I've stayed out of this thread for a while. But now I feel that I should say something. Since you are paying for the ride, it's your taxi. If is all you wanted was a ride, a taxi is exactly what should have been called. If you want something that runs a little deeper than simply a ride to a hospital, you lose some of your discretion in where you go. That's just the way it happens. If you met trauma criteria and they brought somewhere other than a trauma center, you'd be just as quick to go after them for not bringing you to the appropriate facility. They were damned if they took you where you wanted go, and damned if you didn't. Your anger is grossly misplaced, as the facility is where your anger should lie. If you felt that strongly that you didn't want to be there, you could have signed consent of transfer forms and refused to sign the consent for surgery forms. That might well have aleviated much of your "pain and suffering."

A 120 hour course is not sufficient in the opinion of many prehospital providers. But that is the national standard for the most part. If you want to improve that system, don't waste your time, effort and money trying to run an ambulance service out of business (there will be another to replace them, probably with the same employees under a different service name...I promise), instead put your effort into lobbying to improve the minimum standard of prehospital care.

But back to your 120 hour comment, and knowing what's best...and what idiots they are.

Let's delve into some of your history here...

You're a "PADI master scuba diver trainer," that's great. It doesn't apply to your case here. I'm a diver as well. Maybe I'll give you a call if I'm looking to take some more diving classes. It has nothing to do with handling a medical emergency, especially one that's not related to diving.

You're also a "PADI medic 1st aid intructor." Now as I recall, PADI trains to the first responder level, and isn't a recognized entity for certifying someone to work in that capacity. It's a nice course to take (and I recommend all divers without at least that training to take the course), but again it doesn't apply. The EFR course is even less time than an EMT course. So where does your medical training add up to more than the EMT's 120 hour course? My math is showing that it doesn't. Just for your own refrence point. The prehospital hierarchy goes in this order from least to greatest in terms of education and capability.

1. EFR or MRT - Roughly the equivalent I believe

2. EMT-Basic

3. EMT-Intermediate 85/99

4. EMT-Paramedic

Some states have supplemental classifications that allow for modified skill sets, but as set forth by the NREMT, that's the order.

You've "worked in that profession for 5 years." That's great. There are many providers in prehospital care with well over than in experience. Most paramedics went to school for at least two years to provide the care that they do. Your experience as a diving first aid instructor is pushed aside by people with more education (and most likely experience) in their discipline.

You've "seen many stoke,heart attack,and drowning victims,at least 15." Not bad in five years...for the average person. Most professional EMS providers will probably see that in a range from a few weeks to a few months. Congratulations, your five years of experience adds up to what I might see in a typical month working for a busy city service. What exactly what was your point?

"Im no stranger in doing whats right for the patient,esp if theyre LUCID and know whats going on." While you might have your own perception (most likely ill conceived) of what's "right" for the patient, there are state written and accepted guidelines referring to mechanism of injury and where you may or may not take a patient...regardless of their wishes. You're saying this hospital has a reputation for being less than acceptable. Unfortunately, as a prehospital provider we have to look at their trauma rating for a trauma patient...not their reputation. While you get some say in where you go, the acuity of your injuries may dictate otherwise. I most likely would have taken you past that hospital to another trauma facility of your choice. That has to do with my level of training and my level of comfort managing your injuries. I'm also experienced in the field and could justify my decision...as well as not being afraid to go out of the "box" occassionaly when it's appropriate. That being said, I wouldn't fault a crew for wanting to get you to the closest trauma facility. Just so you know, had they gone by that facility and something happened to you...the first question to them would have been why they bypassed an appropriate receiving hospital to go to another. The answer that it was your choice when you met trauma criteria is not acceptable. We have a paramedic in our service that dealt with a very similar situation when taking a child to a children's hospital. The patient had a poor outcome (due to the hospital), but the paramedic was questioned by medical control and I believe attorney's as to why they chose to go past a trauma hospital with the patient. Things are not always as black and white as the common patient would like to believe.

All of that being said, let's say you're suffering from decompression sickness and you want to go to a hospital without a decompression chamber. Should the crew transport you to the hospital of your choice when they don't have the means to treat your condition? After all, you're alerty & oriented...you must know what's best regardless of their training.

Sometimes calming the patient is easier said than done. You'll find people who would have taken you to the hosptial of your choice. And you'll find people who would have followed their regionally accepted protocols and brought you to the closest trauma facility regardless of patient choice. Alert & oriented doesn't always add up to you being given your choice.

In my opinion, your anger is misplaced. The hospital (and more specifically the surgeon) is ultimately responsible for your condition. The ambulance crew did their job and met their expectations by transporting you to a higher level of care. Remember, you didn't have to consent to surgery at that facility. You could have signed the refusal AMA and requested a transfer to the facility of your choice. So who do you blame for signing the consent forms? The ambulance crew?

Shane

NREMT-P

Fiznat,

You and I spoke about this call the other night. I have to agree that adenocard probably wasn't the best case treatment for this patient. I think we've all agreed that the tachycardia was not a true cardiac tach, but compensatory for some other underlying pathophysiology. This is a patient with a poor history, and a poor ability to compensate due to their underlying conditions. The brain cysts raise a curious point too. We had talked about if they were ever biopsied, but you weren't sure. I still wonder if she had something going on with her cysts causing the dysfunction. Possibly increasing numbers, growing, etc.

In this case, since the tachycardia was compensatory the adenonsine wouldn't have been expected to work. As you know, adenosine is a "chemical cardioversion" allowing the heart to reset itself. If the patient is compensating, they will reset right back to the rate needed in order to compensate.

Someone made a valid point that sepsis takes liters of fluid to begin to take effect. Another IV would have been a good start. I'm not sure that with the short transport time that I would have initiated pressor therapy. But definatly fluid challenges. Another IV would have been helpful, although you did say the patient was a poor stick at best.

All in all, it's a learning experience. Like we talked about, I think that with time you'll actually find yourself less aggressive with pharmacological therapies...and more accepting that not every issue needs to be addressed prehospitally. Sometimes being aware of the issue is enough in itself.

You are already starting to grow termendously as a paramedic. And you have a better start as an entry level paramedic than most. Keep up the strong work. It will only get better as you continue to gain knowledge, and more importantly experience.

Feel free to talk to me any time about calls you have questions on. I'm happy to listen.

Shane

NREMT-P

Every patient gets the ABC's done on them. It's a matter of if you catch the manner in which I assess them for the ABC's. Do I walk up to them and physically check a pulse? Look for breathing? Not always. If I walk in and a patient is upright and talking to me, then their ABC's are in tact. If they're unresponse, then I do the "look, listen & feel" approach...or part of it. Sometimes I can check these by visualization alone. The inital assessment of a patient should be a matter of seconds. A quick "hello, how are you?" is sometime's all that's needed. You can gauge a lot by a patient's answer to the most basic questions. Couple that with a quick pulse check and you'll have an idea of if they're rate is fast or slow, and if they're pulse is normal, bounding or weak. But yes, every patient gets the ABC's done.

Don't compare a competition to what happens in real life. People act differently when they know they're being scored. It's easy to get worked up in the competition and leave things out. Gauge someone instead by how they conduct themselves when working with real patients.

Shane

NREMT-P

I am not another basic asking for ALS skills. This is about education and if the ALS providers want to educate BLS providers then why don't they? Let's face it some areas NEED ALS available for their skills, but do we want BLS to call ALS just because or do we want them to know why they are calling them?

Where is the dead horse? Because it seems as though he is about to get yet another beating. It's just the way this seems to be headed...

But I digressed, as far as if we want BLS to call ALS "just because" or if we want them to know why they are calling, that goes to education for the answer. Like I suggested earlier. If you go take an anatomy & physiology course, you'll find that you will come to know when and why to request ALS. Without that understanding, in most cases you are shooting in the dark. I can tell you that I get called for an ALS intercept more time when it's not needed than when it is needed. That's just the nature of the current EMT-Basic program. It doesn't really teach enough to allow someone to think critically in the field, nor does it provide them with enough knowledge to make informed decisions about a patient's condition. In fact, the bulk of the EMT-Basic program can be condensed to "Scene safety, BSI, ABC's & call a medic." Keep in mind that most medics spend more time in anatomy & physiology class then the entire duration of the EMT-Basic program. Now with that being said, there are many people that feel that the current paramedic programs are inadequate. So if people feel that way about the paramedic program, how do you think they feel about the current EMT-Basic program? It really is little more than a boy scout's first aid course.

As far as ALS providers being willing to educate a BLS provider. Most of us are willing to do that, and actually attempt to do so. It's not always taking someone from have little to no understanding of a condition to begin with. There's only so much you can do with a poor foundation to build upon.

So I'm assuming that you are one of the EMT's that can tell a paramedic why you called them and be able to explain it on a physiological level to some degree? If you can, then more power to you. But really, I find that to be the exception and not the rule.

Last point, where was the thread again that asked for the EMT-Basic scope of practice to be discussed again?

Shane

NREMT-P

PS - Spell check found no errors in this post.

What do EMT Basics do? Well that depend upon the system that employs them. If the system forces an EMT B to be a taxi driver and a gopher then that is what will be done. If the system allows the aforementioned provider to perform skills and interventions then that is what will be done. All systems have their fair share of idiocy and excellence. After a decade of seeing many different forms of service and how the levels interact, I feel that EMT B providers are being held back by the ego of the EMT Paramedic provider.

A request was made to have an explanation of what EMT Basics do, see if you can follow.

Airway

o OPA and NPA

o Combitube

o LMA

o King

o LMA

o ETT

o BVM

Of the above the most important is the use of a BVM to maintain PEEP and thus splint open the airway

Breathing

o Ventilation at the appropriate rate

o Proper BVM technique

Circulation

o CPR

o Bleeding Control

o Warming or cooling patients

This covers most of the stuff that we do. EMT Basics are also expert people movers and packaging is something else that is mastered.

In response to what makes them better than the high school kid with a first aid class, simple we come with the ambulance and we don’t really need you EMT Paramedics if you are going to be stupid and wast our time.

Interesting first post to say the least. Refresh our memories please, where was the BLS scope of practice asked? I don't recall reading that particular thread. And it seems as though others missed it as well.

As far as the "ego of the paramedic provider" comment, I find it hard to believe that you think it's an ego thing. In my opinion, this demonstrates your lack of understanding or even ignorance with regard to EMS as a profession and also as to the skill sets of differing providers.

So the thing that makes you better than a high school student with a first aid course is that you can bring the ambualnce for transport? That's good that you have it. Because the scope of practice for a BLS provider is quite limited for a true medical emergency. You're going to need the rapid transport. I think you're misinformed if you feel that a 120-140 hour EMT-Basic course that teaches little to no critical thinking is sufficient to handle an emergency, even over a "stupid" paramedic to "waste your time." It's my opinion that a paramedic is better educated to deem weather an EMT-basic is needed than an EMT-Basic is to decide if a paramedic is truely needed. The educational process for the two are distinctly different. And no matter how you look at it, the paramedic curriculum is far more in depth.

If you want to be a good EMT, then maybe you could take some of your time and sit through an A&P course. Then you might have a leg to stand on. Remember, most paramedics have spent more hours sitting in anatomy & physiology class learning about the human body and how it functions than you spent to become an EMT-Basic. The current EMT-basic program is little more than a glorified, feel good first aid course. In fact, most people including myself feel that the EMT-Basic program isn't adequate for little more than interfacility transfers.

Shane

NREMT-P

8) hey i am new to this site but i only have one thing to say i am in illinois and compare almost 7000 paramedics registered to almost 17000 basics registered face it we dont do it for the money we all need each other we can use each other well when you work together give us a chance guys we'll show u what we can do.

paramedics=army...basics=........MARINES

First, welcome to the city. You have the chance to do a great deal of learning here, and hopefully contributing as well. That way we can all have the chance to learn from each other.

Second, please construct your posts using some form of acceptable grammar. Remember that people's first impressions of you on the forum are based on how you construct your threads or posts. Poor grammar indicates a lack of education, or even worse a lack of effort to make sure you're conveying your points clearly. Spell check is your friend. But punctuation is something you need to do yourself. Your written word on a forum such as this is as good as your spoken word in person. Put forth a good image not only for yourself, but for our chosen profession as well.

Third, this "not doing it for the money" comment doesn't really come into play and has little to do with the topic at hand. Comparing the numbers of providers doesn't do much either. In fact, if the minimum standard to work on an ambulance were at the EMT-Paramedic level then we might see fair wages which would attract people to go through the educational process in order to fill the position. Add to that the fact that there would be less volunteers (if any) and now the field as a whole is in a position to request better wages and working conditions. They're educated, willing to work and there aren't more people giving the job away for free than are getting paid for it. It's hard to ask for a good wage when people give the job away. Where I live, there are few paramedic volunteers but the majority of BLS services are volunteer. So the volunteer EMT-Basic's far outweigh those that are paid. So if the working conditions and wages were better, you'd see a large decline in your 17,000 basics and a sharp increase in your 7,000 paramedics.

We can and do work together currently. That's how many systems are designed to work in fact. The problem is that the system itself is flawed. Given the option of working with a basic or working with another paramedic (assuming both are competent in their job), I would prefer to work with another medic. It saves me from getting burned out from always getting slammed, and it's someone who knows what needs to happen or that can come up with some other ideas with regard to what's happening to a patient. For most EMT's, once you start talking on a higher level with regard to medicine and physiology or pathophysiology they get lost quickly (unless they've had some additional classes or another interest in A&P and medicine). This can be frustrating more often than not. And I am willing to teach them, but it's teaching them from the ground up since the vast majority of EMT-Basic courses don't teach an acceptable minimum amount of material to make a solid foundation for further education. How many EMT-Basic classes really went over anatomy & physiology? Or talk in detail about critical thinking and decision making? With the new providers coming out here, and from listening to other's at places like EMT City; I can confidently say that not many EMT-Basic programs are acceptable.

Finally, your military anaology is a stretch at best. Most of us here are not military and the analogy loses it's value quickly. Especially since everyone's views of each branch of the military is biased or subject to opinion. But since you say that the basic's are the "marine's" of EMS, how would patient outcome fare if their supporting troops were more basics? Patient outcome probably wouldn't change that much since you're limited by your scope of practice. Given a military situation, I'm sure that marine's backed by more marine's could handle their task. It's a manpower issue. Not an educational issue.

The bottom line is that EMT's need to become more educated, and with that education should come a new minimum standard. Until the system changes though, if you want to be a great EMT go take an anatomy & physiology course at your local college. A&P is the universal language of medicine and will help you to obtain a solid foundation to build upon and maybe help you gain a better understanding of where EMS needs to go and why it needs to go there.

Shane

NREMT-P

We have 5mg Haldol & 2mg Ativan IM for combative patients on standing order. I think that chemical restraint definately has a place in prehospital care since safety is always a priority. Once someone is sedated, it should become safer to transport them in the back of an ambulance in an enclosed space. I don't use the protocol frequently, but when I do need it I'm glad to have it and more importantly to not have to call to do it.

Shane

NREMT-P

Whit, I'm not sure what you mean by a circumflexion so I cannot comment on that. It is very rare for kids, especially this young, to end up with cervical injuries. Their bones are mostly cartillagenous at this point and can take quite a hit without any problems. Accicents that result in any form of injury are usually fatal. This is true in healthy kids. If a kid has some sort of underlying bone problem (ie osteogenesis imperfecta) then this does not hold true. Obviously I cannot comment on this kid, but I also said extremely rare (not impossible). Using the NEXUS rules, it does not sound like you can clear this kid (language barrier, can a 2 year old really tell you about midline tenderness?). Not sure where this kid falls on the CCS rules as I am not as familiar with them.

Also keep in mind that not all cspine fxs are unstable (not that you can tell that in the field). I learned that this past week. We had a 24y/o who was running in some shallow water and though it would be a good idea to dive head first into the water. Imagine his surprise when a bunch of rocks jumped in his way and he hit them with the top of his head. This was at 0230 (yes, alcohol was involved). He came in about 14 hours later because the pain had not gone away. CT scan shows a Jeffersonian fx of C1. The fracture points were both to the posterior arch. Called the ortho guys and they slap Miami J collar on him and send him home. I was alittle upset to say the least. So, I did some reading and any C1 fx that occurs behind the lateral masses is stable. This kid will be in the collar for 3 months, but it beats a halo for 6 months.

Great post doc. A clear demonstration that none of us are done learning, regardless of the level that we practice at. Definatly a teaching point here.

Shane

NREMT-P

I work for a BLS service. We run basic level calls for non emergent services as well as back up for our local county service which is ALS. We also are expanded scope too! Most of the time we dont get ALS calls but sometimes your routine bls call will turn to an als in a blink of an eye. I have only had an intercept ONCE.. and it was duely needed. I make the decision if I need one or if i proceed routine or 10-18 (emergency traffic) to the local hospital. Just because I am not a medic does not mean I dont have knowledge or experience than some of the medics out there. I have known medics who basically shit their pants in situations that some basics have excelled in!

First of all, who brought this thread back to life? It was dead and I kind of wish it stayed that way. But on to some other things. Yes, BLS calls an turn in the blink of an eye as you say. What exactly defines "expanded scope?" We don't have that classification where I'm from so I don't know what it entails. And more importantly, how often do you find yourself functioning in that skill set?

I'm glad you make the decision of if you need an ALS intercept or not. That's exactly what your job is. I'm not totally sure where you were going with that.

As for the "just becaus I'm not a medic..." comment, I don't doubt that you probably have experience. In fact, you may have more experience than some medics out there. As far as the knowledge, where did it come from? If you have the knowledge, why not go become a medic and put that knowledge to use? I find it hard to believe that you have the same knowledge base without having attended a paramedic program or some other kind of training. CME's will only go so far.

There are medics that find themselves overwhelmed in certain situations. That's an issue that should be dealt with by dealing with the provider. It's great that a BLS provider excelled in it. Again, their job is to handle stressful situations. Rather than patting a BLS provider for performing as they're expected to, maybe the medic that "shit" his pants needs to be remediated and handled for poor job performance. I'm not overly impressed by a BLS provider who doesn't get worked up. I expect that out of the people that I work with since I expect them to hold themselves to the same job performance standard for their scope as I hold myself to in my scope or practice.

Shane

NREMT-P

A booked regular transfer, or even a "stat" transfer (as they're sometimes called here for emergent situations) has to be booked by the hospital. Not by a patient sitting in the ED and calling 911. So is what you're saying is that if a patient is sitting in the ED and decides to call 911 to go somewhere else it falls on the dispatcher to call the hospital and provide checks and balances to ensure the hospital is handling the situation? Sounds to me like a good way to get seen faster. If I don't want to sit in the waiting room, I'll call 911 and they'll call the hospital for me to get me some attention. The dispatcher must know what's going on better than the triage nurse (who in this case did a horrible job). Where does EMS dispatch come into play when a patient is already in the ED of a legal receiving facility? The real answer is that they don't. This dispatcher didn't handle the call as well as they could have with regard to comments made...but I don't think they had a duty to call the hospital or send an ambulance when the patient is at the hospital. If a patient is in the ED it's reasonable to assume that the patient has been seen by a nurse and appropriately triaged (althought it was a poor job in this case). I don't know about you, but I've seen plenty of patients tell me that their condition is worse than it is. If all the people who told me they were "dieing" and ended up in the waiting room were right, there'd be a much larger issue. It's the role and responsibility of the triage nurse to assess these patients and prioritize them. Again, it's not the role of the ED to provide some quality insurance by calling the hospital and advising them that this is a taped call and that they receieved a 911 call from their waiting room.

I'm sorry to hear that many other hospitals outside of your region would be a higher level of care. The two major hospitals we deal with are both trauma centers (one is a level I and one is a level II). This gives them a large capacity of handling patients. However, even when these hospitals are on diversion they still manage their walkin patients. Up to and including MI's, GSW's, etc. If a patient needs to be transferred somewhere, they do it.

I guess a better answer would have been if the hospital couldn't handle this patient due to patient overloading then they should have been the ones to book a transfer for the patient to another medical facility. They didn't feel this was warranted for whatever reason they had. In this case it's the hospitals fault to own. Not that of anyone else's. Not the police department, fire department, EMS crews and not even dispatch.

Shane

NREMT-P

... the ED staff felt it was best for the patient to seek medical attention else where.

I don't believe that hospital staff can feel it best for the patient to see medical attention elsewhere UNLESS it's for a higher level of care. If the hospital is so busy that they can't handle a case that might show up by private vehicle or by ambulance, then the facility is negligent for not going on diversion. Even in that case, they still have to handle patients that walk in as far as I know.

And as far as calling them and telling them that the call is being recorded and that this is an emergency, the dispatcher can't really provide that information as they have done no assessment of the patient. It falls on the facility to handle their incoming patients. It's not the role of dispatch to provide checks and balances for a receiving facility. This would be the closest appropriate facility for the patient.

Shane

NREMT-P

I think they are going to get successfully sued for this one, big time. All the family needs is a few doctors who state that given her present condition, if she would have received proper care at XYZ hospital in XYZ amount of time, she'd be alive today. Thats it. I don't think it's going to be a far stretch from that point, to go after negligence.

I'll see your doctors that state that "given her present condition, if she would have received proper care at XYZ hospital in XYZ amount of time, she'd be alive today" with doctors of my own that state that the hospital has the abilities to manage this patient and I'll back it with case studies demonstrating previous cases within the hospital that have been managed appropriately.

A law student could handle that defense without much trouble. The case against the hospital is a whole separate issue however.

This isn't a case of a patient going to an inapproriate facility and being refused transfer and dieing. This is a case of a patient being neglected in the hospital. This is a case that from the sounds of things should have been able to be managed by the hospital, they just chose not to do anything with the patient. You could have the negligence case against dispatch IF (and only IF) you were to demonstrate the hospital was unable to provide care for the patients condition (due to medical level, not staffing) and that dispatch refused them an ambulance while the dispatchers knew the patient was not at an appropriate facility. Example: A patient having an MI in a facility without a cath lab.

Let's change the call slightly. Dispatch sends an ambulance and they transport to another facility and the patient dies on the way to the hospital. Who's at fault now? You've taken a patient away from a capable treatment facility and taken them farther from care. Now who's negligent? In that case, by all means go after EMS and the dispatchers.

So the bottom line remains, the patient was at the ED of a facility that should have been capable of managing the condition. They didn't manage the case properly (if at all) and the patient died (suffering "damgages" for legal terms). EMS or the dispatchers contributed to the patients condition or deterioration. They were at an appropriate emergency medical facility.

Shane

NREMT-P

We've been dispatched to the hospital grounds before. You CANNOT refuse action when someone calls 911. That's called negligence. We've had people call 911 and step outside the doors and state they want to go to another hospital for treatment. They sign out AMA from said hospital and we transport. You can't tell them no as long as they sign out from the first hospital.

I have been dispatched to the hospital too, in the parking lots most commonly. There is a difference between someone being inside of a legally defined and registered emergency department and just being at the hospital. That line changes things significantly. If you're in the ED, the hospital is being negligent and not the EMS service. If the patient is outside somewhere, or outside of a designated "patient care area" then EMS has a duty to act and could be found negligent.

Based on how your post is worded, someone who is tired of waiting in the ED (patient room or waiting room) can simply call 911 and we'll come in and take them from the site of higher care to go somewhere else. Patient care areas and emergency department are the key words here...not hospital grounds.

Shane

NREMT-P

I'm going to say no as well due to the fact that the patient was at a hospital with a legally designated emergency department. The problem in this case falls on the hospital staff for not recognizing and treating the problem as it should have been. EMTALA certainly plays a role in this kind of scenario. It's unfortunate, but we have no control over the hospitals treatment of a patient.

Shane

NREMT-P

I would prefer it explained but since he didn't armchair it, I'll take a short humble opinion. As far as 12-leads on SOB patients, unless they have cardiac complaints we are not required nor is it even referenced in our protocols. The only time we are required/asked to perform them is chest pain/ACS patients. You can bet your posterior that it won't happen agian.

I respect your opinion but just because someone didn't treat a patient the way you would have treated a patient does not mean they were wrong. I have worked a few different regions/states in several different services, every place puts emphasis on different things but the care is generally the same. Something you find as a major delinquency in your area may be nothing but provider discretion in another, BUT IT DOESN'T make it any more right or wrong.

Not once did I say that you were wrong in your treatment. I've actually stated repeatedly that this should be a learning experience for those who read the thread as well as yourself. And if you really want to get technical, you never posted exactly what was done for this patient. This has been strictly about the EKG other than knowing what the patient's complaint was. I'm glad that you won't let this happen again in your practice. It demonstrates that you've learned from the experience and it will have a positive impact on the patients you might come into contact with in the future. That in itself makes this call worthwhile, up to and including the discussion.

With regard to what's expected of your region, I don't understand why a patient complaining of shortness of breath wouldn't be suspected to possibly have a cardiac etiology, symptom or complaint. How do you determine the need for further cardiac work-up? This is NOT meant as a bash, I'm just looking for insight into how providers in your service come to this determination. A patient in heart failure or having an MI are great examples of someone that may be complaining of a respiratory complaint while their underlying problem is a cardiac in nature. Maybe you are taught some different assessment techniques to use that would help others that read the forum (meant with no sarcasm). I'm all about learning and enjoy learning how other services work. I often pick up things that I can incorporate into my daily practice.

Shane

NREMT-P

Might I suggest downloading and reading this from Bob Page's download page. It's a power point titled "Advanced Dysrhythmia Course" and is loaded with great information that might shed some light on the subject.

Shane

NREMT-P

This was the kinda thing I was looking for, I knew before the run was over that I should have done a 12-lead. I have never done a 12-lead on a shortness of breath patient until now. You can bet that I will be doing them from now on. My frustration was with the Cardiologist, how from a 2 second glance and no history did he know/think this wasn't V-T? Yeah my measly paramedic degree is no match for his royal education, but he could have been far less arrogant and made this a teaching moment!! :x

I'm confused, I thought you wanted to know how we arrived at our determination of what we believed it to be. He just said it's VT without any explanation and you're okay with it? Just kind of confusing from where you were earlier in the thread in the information you desired.

I'm surprised that you had never done a 12-lead on a shortness of breath patient. Where we practice, it's a standard of care and it's enough to have you pulled into the office of the medical director for having not done one when it was indicated. In this case, with the heart rate I would say a 12-lead is more important than an IV. As soon as the patient is put on the monitor and I see that it's wide complex (as long as the patient has a pulse) my next step is to do a 12-lead. I guess ultimately it comes down to what your protocols dictate and what your medical director expects. If a 12-lead is not in your protocol for shortness of breath patients, then use this case as a way to change your own practice and better the care you provide for the patients you come into contact with. Again, it's not meant as a bash as much as it is a means of education for everyone who reads this thread. So please, don't take it negatively even though we keep coming back to the 12-lead. It's an example of importance.

As far as the cardiologists attitude, unfortunately some doctor's are just like that and there's nothing else you can do about it. You could always take the strip and talk to your medical control or another doctor that you're comfortable approaching and getting their thoughts on the matter. Any pro-EMS physician should be willing to take a minute and talk to you.

It's also down to the scene as well and time from hospital and was the patient symptomatic to warrent a 12 lead

Distance or not, a 12-lead should generally take less than one minute to perform from set up to capture. As far as if the patient was symptomatic or not, he called due to being short of breath from my understanding. So I would take a patient with shortness of breath, that's tachycardic with a wide complex to be symptomatic. I'm glad that you agree that one should have been performed in this case. But I'd also still like to know how you arrived at your determination that this patient was in V-Tach from the three lead?

Shane

NREMT-P

The reason I asked is this cardiologist took one look at the patient and a 2 second glance at the monitor strip and said "your wrong" and walked out of the room. He didn't have any patient history, vitals or nothing else but he was able to make the determination. I posted this strip to see if I had missed something, wide complex, bizaar, unifocal tachycardia.......yeah maybe I should have done a 12-lead but I didn't have time. I suppose that some of you are perfect but me.....I make mistakes and have oversights on occasion.

You were looking for input on the EKG and why this is or isn't V-tach, and also what else it could have been. One of the best ways to determine what else this might have been is with a 12-lead. Myself, I'm not convinced that it's V-tach either. Seeing what the rest of the heart is doing would be most helpful and that's why we keep going back to the 12-lead that's missing. This call merely presents a teaching point that you can tuck away for future refrence. Don't underestimate the importance of a 12-lead in a tachycardic patient complaining of shortness of breath. That 12-lead just might help you to determine the underlying cause of the patients shortness of breath (respiratory vs. cardiac etiology).

We were trying to help you...not bash you. Remember that anytime you post a case on a public forum, you open yourself to questions, comments and even criticism. If you dont' want everything that goes with it, well...that's a decision you have to make for yourself. Don't take an internet forum so seriously. This is a place of learning for most of us. We all try to learn from each other. And part of that learning process is making mistakes and recognizing them. Most people won't be harsh over a mistake, only when the mistake is repeated. There's things that all of us do now in our practice because of mistakes we've made in the past getting where we are. You can choose to take this constructively...or not. That's a decision for you to make. If it were me, I'd try to find a way to make myself a better clinician for the future. Noone's saying you're a bad medic, but we ALL have room for improvement.

Shane

NREMT-P