HERBIE1

Based on your bio, it says you are an EMTB student. As such, I'm assuming you are not in a position of authority. Sounds like someone in charge needs to be notified ASAP. If nothing else, AT THE VERY LEAST, let a supervisor/instructor know that there is a provider out there who is dangerous. I don't know what the rank structure of this service is, but there must be someone responsible for QA/QI, and who could start by reviewing the PCR's. Best case scenario, a supervisor/training officer needs to do a field evaluation and monitor this person. He is not only a crappy provider, but a liability to the service/company.

Kiwi- Thanks for posting this. Clearly your system is more progressive than many around here. Our profession has evolved over the years- from basic treatment and simple transport to advanced procedures. There were no provisions such as the protocols you listed. Our job was simple- treat and transport, with the occasional refusal. Because our system has become so overwhelmed in recent years, I think policies such as yours are inevitable- for the sake and viability of the providers as well as the hospitals. Will this happen any time soon? Nope- not until we see tort reform. This is not about being lazy, it's about proper utilization of resources. People seem to forget about the "E" in EMS. If time, money, personnel, and space at ER's were not an issue, then policies such as yours would never be necessary. If we are morphing into more of a public health/.primary care role, then it means major changes need to occur in the whole system. Education, equipment, staffing, pay, credentialing, protocols, public service announcements- it would be a huge shift in how we view and provide prehospital care. The rest of the system would also need to be changed. Example: In this area, a couple years ago, a large teaching hospital opened multiple satellite outpatient centers around the neighborhood to help alleviate a severe overcrowding in their ER. They provided PSA's, ads, and plenty of explanation as to the location and purpose of these facilities. As with most ER's, many of the patients they saw were not emergent, or had any acute issues but flooded the ER nonetheless. The ER was(and still is) forced to divert ambulance transports every single day- often multiple times within a 24 hour period. When their clinics opened, the population was up in arms about how this was somehow downgrading the care they received, and since the residents of the area were black and poor, they of course saw this change as being racist and unfairly targeting the poor. The clinics went severely underutilized- people simply preferred the idea of allowing someone else to make their decisions for them. The ambulance ride, the top level, all in one location care that required no effort on their part to access. That ER remains severely overcrowded to this day. As it stands now, for most places I see enormous obstacles with implementing a plan such as yours here. I do not know this for a fact, but I suspect your society is not nearly as litigious as it is here in the US. Yes, our policies are enacted allegedly for the benefit of the patient, but in many cases, the underlying reasons are actually to prevent liability to the provider, their service, the system, and the medical director.

This may be true, (and I totally agree with you, BTW) but it's also the standard procedure in most places- at least around here. We don't get to decide who we should and should not take. If someone wants a taxi ride, then that's what they get. The legal language states that an "emergency" is defined by the caller, not the responding crew, meaning if the patient convinces the call taker their problem is legit (AKA- lie), then they get a response. Even if the crew finds out the complaint as dispatched was total BS, we have no mechanism to refuse to take the person. Thus, in most places we have overwhelmed systems and overcrowded ER's. In this country, lawyers run the medical field and dictate how we do our jobs.

No slam- simple observation. The problem is, the terrorists have already won. Their purpose is to disrupt our lives and our way of life. Because they know we are insanely worried about being PC, we do not profile or target the actual people who are a threat. LIke it or not, 99.9% of terrorists have 2 things in common-a bastardized version of Islam as their religion and/or Arab ethnicity. As such we have ridiculous notions like patting down little old ladies, kids, and taking away nail clippers and limiting shampoo to 6 ounces. The fact that we willingly submit to these things means we have a false sense of security, AND we look like fools.

If that were my child, I probably would have ended up in jail over this. I GUARANTEE that no minimum wage cop wanna be flunky would be feeling up my 11 year old daughter. As the mother said in an interview, this kid assumed she did something wrong and was upset over the incident..

Nothing on earth worse than when your child is sick. Positive energy and thoughts your way, and as others have said, thankfully this sounds like a very treatable problem.

DON'T DO IT! Get out before it's too late!! Just kidding. Congrats! Sounds like you are way ahead of schedule. What fun is that?

Scheduled meals and breaks? Are you kidding? Sounds like they work in a bank, not an emergency service. If those are really their benefits, then it certainly sounds like the remaining workers could pick up some slack. I wonder what their salaries are in comparison to those on this side of the pond.

Best of luck, bud. Sounds like this would be a great opportunity for you. Only drawback- less face time with your bride to be. Not to rain on your parade, but working nights is hell on relationships- especially if the spouse is working days. I think it's even harder than working 24 hour platoon work. I've done both. Not to fear-if you both are committed, you simply find a way to make it work. Over time, it becomes your new "normal".

What type of training do you receive for this? Obviously you need to be familiar with antibiotics and their coverage spectrums, as well as wound closure tips.

Maybe ask your CC to step back when someone asks for information and you can provide the answers. It can be intimidating to talk with the docs sometimes- especially if they are the holier than thou, MD (me doctor) type. LOL I've also found that younger/newer providers problems are generally due to 2 issues- the deer in the headlights fear, or the cocky, arrogant types. Most docs can handle the fear- especially since they are used to dealing with brand new med students. They certainly do not like the arrogant, know it all's and are more than happy to cut them down to size as needed. Will you find the occasional a'holes? Yep. Minimize your interaction with them because regardless of what they are, it's still their show and you will never win a confrontation with them. Stand your ground if you are right, but remember, ultimately their decision and opinion is the one that counts. It's just about practice, confidence, and being assertive. As long as you know your stuff and have done the right thing, you have nothing to fear. You may be surprised- many of the more aloof docs adopt this persona, when in reality they are just as goofy, twisted, and down to earth as we are. They especially appreciate information they may not get from the patient or their family- interpersonal family issues you experienced, condition of a home if pertinent, contradictions in the patient's story vs the family, etc. After working with docs in ER's for many years and having many as personal friends, I no longer have the intimidation factor to worry about. Just realize these docs are being pulled in a million directions- especially in a busy ER. Lab reports, consults, Xray results, contacting primary doctors, monitoring medical students and residents in a teaching hospital, listening to their reports, answering the radio, giving reports to an admitting service, clerks and nurses asking questions, and of course, patient care. Don't take it personally if they appear brusque. Be succinct with the report or question, and try to pick an appropriate time and place for the interaction. Always be professional, and always use proper terminology. Most of the docs are more than willing to answer questions, they appreciate getting information- especially when it can help determine how to proceed with a patient, and they always appreciate the fact you take more than just a passing interest in the patient.

In many systems- especially fire departments- you are dealing with paramilitary organizations. I understand the need for hierarchy and someone needs to be in charge or you would have absolute chaos. The problem is, in medicine and the fire service, the real life situations often become collaborative efforts, with everyone doing their assigned parts, but usually all are allowed input. Yes, there is a time and place for discussion or thinking through a problem- ie on an extrication, but there are also times when you simply listen to your superiors and do your job. The hard part of course is understanding the proper time and place for those "discussions". One of the reasons I became an officer was because many of the "old timers" I worked with when I was new were poor medics, had poor interpersonal skills, and often times I feared for my license and/or my safety. I figured if I was going to get in trouble, it would be due to my own mistakes, not those of someone else. Our problems arise when the person in charge is not the most experienced provider, but someone who simply enjoys the title, and the small increase in pay. They may be working with someone who has many years more experience than their "superior", and it's still up to that subordinate to ensure things are done the right way- regardless of their rank or status. Obviously in a medical setting, those decisions are vital- morally, ethically, and legally. As you say, being in charge is a good thing. Scary at first, but as you gain confidence and experience, the decisions you make become easier. If you are a quality provider, when you are in charge it's reassuring to know that the best possible care will be provided for your patient. Yes, much of our job is "cookbook" and routine, and anyone with a basic knowledge can handle it most of the time. You really earn your money(or title) when things are dicey, it's a strange situation, or all hell is breaking loose. Sounds like you have your head screwed on straight, Ugly. Good luck.

Sending good thoughts and positive vibes to the Ruff household! Congrats, bud.

Your welcome. Quick question- "CC"? Is this crew chief? Although I know there are many different configurations and roles for providers, I sometimes forget the role of internal politics. I have the luxury of having a partner who is the same provider level AND experience as myself. Even though I am in charge- at least in terms of the department, if my partner sees or hears something important that I may have missed, he can and will speak up without reservations. It's his license on the line too. Our roles are interchangeable, even though I am primarily responsible for airway and the report, it's not etched in stone. The situation dictates what needs to be done. Maybe I'm in a mood where the nurses are pissing me off and I don't want to talk to them- he will handle it for me. Maybe he's under the weather and does not feel like starting an IV- I'll take care of it. It is a nice position to be in. Yes, technically it's supposed to be all about the patient, but in real life, we know squabbles and politics do come into play when providing patient care. You may step on a toe or bruise an ego, but as long as you are acting in the best interests of your patient, in the end you will be OK.

Excellent point. I agree that we- and ER's- DO provide primary care in a lot of cases, but not officially. We advise on proper procedures for taking meds, safety tips, advising follow ups, explaining discharge instructions or medication actions, explaining procedures and the purpose of various tests and exams, but again this is not our primary function. It's a role that we have grown into because of the problems with the health care system. There is also a subtle, but appreciable difference between officially adopting this new role and providing the information during the course of our primary duties.

Whether or not our reports are taken seriously varies wildly- even in the same ER. Some docs really want a verbal report- especially on a critical patient. They want to know what we did and don't have time to read the written report. If I feel a nurse has not taken my verbal report seriously and there is an issue I want to stress, I try to wait until the doc goes in to see the patient(generally on the sicker ones, since the stable patients can wait a long time before the doc goes in.) Example- Recently we had a guy who as mid 60's, PMH of ETOH abuse, and seizures. His roommate said he heard the guy making funny noises, found him awake, no shaking, but nonverbal. He called it a seizure. The guy was completely lucid when we arrive, but could barely lift his head off the couch. He denied ETOH- we saw no evidence of it, and he said he was compliant with his meds. Mildly hypertensive, but I honestly cannot recall his vitals although everything else was essentially WNL. The patient was a poor historian, and getting information from him was like pulling teeth- he did not want to be bothered and denied having a seizure. After an exam, we realized this guy had left sided weakness. Further information was he had a history of a car accident 40 years ago, which resulted in a loss of a kidney, spleen, and he had extensive damage to his left leg, which left him with decreased function in that leg. He could not explain the arm weakness- it was new onset- approximately 2 hrs ago. As I was interviewing him further, the man began to fix his gaze to the left, which eventually progressed to a grand mal seizure. I gave Valium and within a minute or so, he was verbal again, but post ictal. Thankfully the receiving hospital was also a stroke center. I had already given the radio report before his grand mal seizure, so when we arrived at the ER(not the telemetry hospital we called), I notified the nurse of the changes. There was simply no time to recontact medical control AND treat the patient. She seemed fixated on the alleged seizure we were initially called for, ignored the weakness, and all but ignored the rest of the report. I completed the patient report and went back to the room to drop it off when I noticed the doc in the room. I interrupted him- politely- and quickly explained the whole history- his PMH, and he said something to the effect of "Well, that certainly changes things- I was told this was a simple seizure." He was worked up for a CVA, we were still within the allowable window for a fresh CVA, but I honestly have no idea what the outcome was. It was clear that the doctor was incredulous that so much pertinent information was left out of the report the nurse gave him. He took my run sheet and .proceeded to read it very carefully. He was quite appreciative that I took the time to directly brief him, and since then, if he is working, he always asks a couple pertinent questions as we roll by- even before he officially sees the patient. The thing about suicidal patients is that means they need a security stand by in an ER, a psych consult, and sadly I have seen nurses essentially ignore claims of suicidal thoughts. When questioned about it, the nurse says that the patient didn't really mean it, they are playing the system and the patient knows it generally means they get an overnight stay until they determine the patient is not a threat to themselves. Dangerous assumption to make, IMHO. Point is, you simply cannot assume the proper story is being relayed to the people who need to know. If in doubt, talk to the doctor directly since it's their ER, they are responsible for every patient, and it's their license on the line if something goes south.

Hospitals supply discharge instructions to all patients. They have also come a long way from a simple- "come back to the ER or call your doctor if your symptoms worsen". There are detailed, disease specific sheets that explain most of the potentially serious complications that may arise. Compliance with those instructions is up to the patient, so I would not reject something like Dermabond in the field on that basis alone. I still think that in most cases, we should not be doing wound closures in the field, for reasons I have listed before. Additionally, I would say there are probably legal implications because our purpose would be transformed from emergency care to more of primary and/or definitive care. I'm no lawyer, but I think certain liabilities we do not deal with now would suddenly come into play. Yes, expanding our scope of practice would probably keep us relevant, and may be the wave of the future, but I think there are many hurdles to overcome before that can happen. One would hope that with our newly expanded roles, better pay and benefits would come, appropriate for someone assuming a more evolved role in health care. Would that still be cost effective? Would the increased liability prohibit such an expansion? Would there be blow back from the established medical community? Again- in most cases, EMS will not venture much beyond where we are now unless the entire system is changed. If a crew averages 20 calls/day, how can they continue to provide EMERGENCY service if they begin spending a lot more time with patients? The fundamental mission of an EMS service is to provide EMERGENCY care and transport, and if we started doing wound closures, we become more of a rolling clinic. How will a provider/municipality be reimbursed for that, especially when so many patients are indigent or on public health assistance? Interesting ideas, but without concrete answers- particularly those that deal with compensation and reimbursement- as well as essentially a total transformation of prehospital care, this idea will probably stall.

I agree with firemedic. Unfortunately, many docs do not read our PCR's, so I would speak directly to him/her. Too often important, nonmedical details gets lost in the report from the nurse to the doctor. I also assume it was a different doctor on duty after the first visit. Explain the situation, explain the potential liability for your service, and it will be clear to the doctor it's also a liability for the hospital. I don't know the laws around your area, but if someone expresses suicidal ideations around here- even without an attempt- they get an automatic consult with a mental health/social worker/psych professional of some type. The onus is then on the hospital staff to "prove" the person is not really suicidal. Does the hospital have a crisis worker/psych department, or social worker on staff? Notify them directly. Other than that, you are right- do not allow ANYONE to let this guy refuse, advise them to document the heck out of everything the patient says, everything they see on scene, and as much prior history as possible. As was mentioned- there is only so much you can do, but clearly this guy is crying out for help. If he was truly serious about suicide, he would have done it by now, but the odds he will become successful on a future attempt are very high- especially if he feels his issues are not being addressed. Good for you for taking notice and not letting this guy fall through the cracks. Sadly, there may be only so much you can do.

Welcome, and congrats on your upcoming nuptials. Your fiance is a bright young man and has a bright future in this business. Even though he's young and new, his maturity is clearly evident by the quality posts he has made here so far. I think the fact that you are posting here is a great idea. Too often the significant others of folks in this business have no idea what our jobs are like. Even folks in the business- nurses, PT's, CT or MRI folks- really cannot understand, although they have a better idea than say a person who works a 9-5 office job. Congrats again on the engagement, good luck in nursing school, and if you have any questions, don't be shy.

Well, on the plus side, it seems you have progressed to a level usually reserved for folks with more than 3 years experience in the field. I'm not sure exactly when I got to that point, but it was indeed longer than 3 years. My call average for the first 20+ years was 20-30 in 24 hours. I have no idea how many total calls that was, but I used to work a rig that has been ranked in the top 10 across the country for all that time and still is- if that tells you something. Several factors come into play here. 1. Your partner. If you have a good partner, this minimalist attitude is usually delayed for awhile- regardless of how busy you are. 2. Your system/working conditions/pay. If for the most part you are satisfied with these things, it will also delay the onset of such attitudes. 3. Your perception of the job- ie- did you realize what you are getting into from day one? Were you wide eyed, thought that every call was a "real" emergency, and were devastated to learn folks actually call 911 for things like stubbed toes, foot pain for 3 months, and rides to get medication refills? I eventually "hit a wall" and became very frustrated with all the BS. As you probably know, in the busy ghetto areas, there are generally 2 types of calls- the completely routine, nonemergent taxi rides, and the folks who find new and creative ways to die. There seems to be no in between. The ones who are really sick are generally obvious, and so are the others. Or so I thought. All it takes is a couple folks who appear to be completely stable- ie the same drunk you've had for years and they suddenly are really sick with a massive GI bleed, you let your guard down, and it turns out they are a half step away from meeting their maker. It scares the hell out of you, and you realize that complacency kills patients and careers. If you are doing this job for the right reasons, it will be a wake up call. It was for me. Part of the solution for me was taking a step back, and going back to school on my days off. I got my masters degree, and found a spot in administration for awhile. Problem was the position was actually a pay cut. 40 hour week, no holiday pay, no OT, AND I had to pay for parking, gas, and the occasional working lunches. I really enjoyed the new environment and challenges and would still be there if I could afford it. I had to leave and go back to the field, but it gave me a new perspective AND a new outlook on the job. I have a great partner, am on a rig that is a lot slower, but we still get a good mix of trauma and medical/cardiac calls. For the last few years I teach a class I created(EMS administration) part time for a Fire science bachelor degree program. I get to impart my "wisdom" on the next generation of providers. Teaching will be my next career when I am ready to leave the streets for good and retire. (Maybe 5 more years or so) Is this the path for you? Who knows? You need to figure out why your attitude slipped or changed, and see what you can do to rectify the problem. Change of scenery, new partner, new rig, new position, work for a promotion, go back to school, teach- you need to find your outlet, your own solution and your niche in the business. You have a long way to go before you are done. Do I still get frustrated? Yep. Do I let it affect my patient care? No, but if it does my partner will gladly kick me in the arse to remind me. Hope this helps...Feel free to send me a message PRN. Good luck.

The problem isn't just with the agencies themselves, it's all the associated lobbyists and PAC groups that go along with them as well as the perks they use to influence the legislators. Many of the efforts of these agencies are either duplicated at the state, county, or local level, or are simply not needed. It's one thing to eliminate an unnecessary and/or redundant entity, but it's quite another for Congress to cut off their own gravy train. This president has only compounded the problem by creating even more czars and agencies to monitor and oversee other agencies- it's like incest, and it's only going to get worse. Obamacare alone has ensured even more red tape, bureaucracy, and oversight. If we eliminated just half of those alphabet soup agencies, think of the hundreds of millions we would save.

The only thing this tells me is that neither side is seriously about addressing the problem. The cuts made are fine, but are also a drop in the bucket compared to what we need to do. Change my arse. We're involved in yet another conflict that does not concern us, our debt is astronomical, as is our deficit, the closer we get to implementing the total Obamacare package, the more it costs us, gas prices are through the roof and only getting worse, unemployment is still around 10%, the housing market is still in the crapper, and the economy in general is on the verge of an inflationary spike. These guys are arguing over comparative peanuts- if you can call BILLIONS of dollars peanuts. The pie in the sky dreams of liberals sound great on paper, but as we can see, are simply unsustainable- and in a lousy economy, they are not only impossible, but irresponsible and reckless. Difficult choices need to be made, and unless we want a total collapse of our way of life, we need to make some drastic changes. We have entire departments and agencies in our government that never used to exist. We got along just fine without them, and now they have only become yet another sinkhole to lose money into.

To me this falls under the advanced scope of practice umbrella. In some areas it makes sense- fiscal and practical, in others it does not. In a busy urban system for example, clearly this idea would be a non-starter. Think about the idea of intubation and other advanced procedures we perform. It was not that long ago when there was a huge backlash- no way should someone without an MD be able to do surgical crics, intubations, needle decompressions, etc. With PROPER training and oversight, I see no reason why EMS providers cannot use something like Dermabond- given the right circumstances.

Ruff makes an excellent point. Like anything, proper training is essential. Is it a clean lac, or does it have jagged edges. Is the wound macerated? I would say that something like this should require training under a doctor's supervision for awhile to ensure proficiency. I was taught to suture by an ER doc years ago. Is it hard to do? Not really. Requires a bit of manual dexterity to tie the knots, etc. Is it difficult to do WELL. Yes. Poor technique yields a nasty scar. Same with using Dermabond.

We don't use it, nor am I aware of anyone who does prehospitally. Seems like it could be useful- if you verify current tetanus status, properly irrigate and clean the wound, etc. I would be concerned about the possibility of infections and liabilities since we would not have the ability to prescribe prophylactic antibiotics. Seems to me most companies/municipalities would not want the added head ache of liability but in some situations, I see it being useful. Rural settings, limited access to care, advanced scope of practice providers, etc. I know folks who have "acquired" Dermabond and used it for themselves and had no problems, but to me it's a risky proposition to put into our treatment arsenal.