Bieber

I like to read (used to read more fiction, pretty much all work or work-related stuff nowadays), play video games (Skyrim and Mass Effect lately), learn and learn about new languages (used to be a lot more into that before I got into EMS), read about space/science related stuff. We also recently got an Australian Shepard puppy which is taking up a lot of our time...

When adherence to protocol overrides our mission to provide good patient care, medicine fails. This story may be the one that finally reached the news, but harm to patients in the name of protocol happens every day in this country and in our industry in specific. Hopefully this tragedy will help encourage people to do what's right for the patient instead of what's right for the protocol. I know when my hour comes, I don't want to be injured or killed by the actions or inactions of those who are more concerned with following procedure than with saving my life.

Oh Lord, to be young and gullible again. Scientific studies are no more unbiased than what you politicians tell you. Studies are funded by someone, and often the outcome of the study slants towards whatever drug or technology that the company that donated the money wanted it to produce (not always, but often). AHA has put out numerous scientific studies over the years (I have been at this almost 30), changing the ACLS drugs to whatever was deemed to be the drug of choice after the last ACLS book expired. Guess what, cardiac arrest survival rates have not changed any despite all of those expert scientific studies and STATISTICS that suggested that the old way was stupid and that the new way will save everyone.

ACLS has to change the curriculum every few years to sell more books to us, and that is all this is about. In a controlled setting like an OR, and for a short period of time, a supraglottic airway is sufficient, but in the field, the ETT is king. And to correct the rookie who stated that vomit in the airway is due to over inflating the stomach, I have worked two arrests at buffet restaurants this year (2013) where the vomit was in the airway before CPR was started, not to mention the numerous GSWs to the face (or other facial/head trauma) that put tons of blood in the airway.

Young is good. Naive is good. Naivity is the fountain from which novel ideas flow, unimpeded by the blockage of bitterness and inflexibility. As far as gullible goes, I think the greater harm here is to be gullible enough to really believe that single-digit survival rates are the best we can do, and that's exactly what we're getting out of tubes and drugs. That is the old way. It's time to try something new, something radical, and something which maybe, just maybe, will give us some real, dramatic increases in survivability.

As far as anecdote... well, I don't really have much use for it, nor do I think many others on these forums do. I think that's why most people who come to these forums are attracted to them. Because at the heart of it, they come here seeking more than what they're finding in the EMS community today. Something more than the anecdote-filled, unscientific dogma and catch-phrase-filled culture that proliferates our industry...

It's awesome that you're passionate about something, but at the end of the day, don't you want cardiac arrest survival and survival to discharge neurologically intact and with a good quality of life post-discharge to be something routine and not just a "handful in a career" type of deal? At the end of the day, most people who die die with good reason... they're old and infirm beyond what is compatible with life. But for some, we have a real chance at returning productive life to folks. Why squander that with unproven treatments like epinephrine, intubation, and transport of active-arrests? If we just start from the bottom, from the very basis of science, that nothing is true until it is proven, and work our way up from there, we will accomplish a million times more and uncover the truth to so much more than we will trying to insist on the veracity of something that (paradoxically) is proving very difficult to prove: that ETI is beneficial.

What do we know works? I mean really KNOW, backed by irrefutable evidence? That chest compressions and defibrillation increases survivability.

What do we NOT know works? What does NOT have irrefutable or unquestionable evidence? PPV, ETI, drugs.

What do we know DOESN'T work? What has been discounted, disproven, etc? Transporting active arrests.

Even you have to admit that there is a lot of questions surrounding the true benefit of ETI, when you start quantifying and qualifying it. Should we be routinely practicing that which has not been irrefutably proven true? Or should we strike it out and go with what we KNOW, and treat everything else as "in need of testing" until proof of benefit appears?

I still don't understand departments that send a fire truck, a quick response vehicle and a ambulance to a medical call. Add a couple of cop cars as first responders and maybe a volunteer or 12 and you get my drift.

Seems like many departments just overkill these things.

Sure there are times when that much help would be warranted but on a simple call, do you really want that many emergency vehicles responding from different directions thus increasing the risk of accidents?

I just never have understood the justification of sending upwards of 10 personnel to a fractured ankle or simple sick call.

A cardiac arrest is one thing but then again, how many people total will you really use to work a code?

I agree... tremendously. We recently adopted pit crew CPR and CCR, which is awesome and great. But whereas before we'd get a squad and an engine and maybe a medic supervisor, now on every code blue we get...

Ambulance (x2 paramedics)

Squad (x2 EMTs/rarely medics)

Engine (x4 EMTs/rarely medics)

Medic Supervisor

FIre Medical (not sure why?)

All to have a minimum of 3 people to handle compressions and ventilation (after x3 rounds), plus the medics from the ambulance to do IV/IO access and drugs, and run the monitor... It's out of control, and honestly fire's starting to get obnoxious on codes. Fire's role is strictly BLS in codes, so I'm unsure why we need x7+ EMT's to do what could be handled by 3... Not that we're a whole lot better with 3 paramedics where 1 would suffice most of the time...

Unfortunately, it's not just code blues but most calls that are getting overkilled and over saturated with providers.

Powerful stuff.

http://www.danoah.com/2013/02/the-bullies-called-me-pork-chop.html

We've gotten a bunch of snow so far, though we're gearing up for round two here this morning. I don't go back to work till Friday, really hoping they've got the streets all cleared out by then.

@Defib: Sure, why not?

We've moved to doing CCR for the first 6 minutes of a code here, combined with a greatly decreased emphasis on intubation (as usual, to the chagrin of many paramedics). As a result of this, our ROSC rate has I believe doubled. As far as intubation or PPV, I'm still waiting to see evidence that they are beneficial to the vast majority of SCA victims... It seems like from what I understand of the science and from having listened to Dr. Ewy (one of the creators of CCR) that there's really not a tremendous need for PPV in the vast majority of SCA patients. (And it sounds like avoiding PPV also helps to avoid a "vomitcano" as well.)

The tube is fun, the drugs are fun, but where's the evidence to support their use? We can mix and mash the data however we want, but the fact is cardiac arrest survival rates have stayed dismally low since we first began resuscitating people... the only systems I have heard of who have managed to defy this trend are those with either very high laypeople CPR rates, or places where CCR, therapeutic hypothermia, etc are being done.

If we have to get all of the stars lined up just right to try and make intubation of SCA patients something beneficial, and its benefit isn't so great as to be intrinsic to most cardiac arrest scenarios, and if survival rates haven't improved since we've been doing it, is it really this horse we ought to keep beating to death?

Man Beibs, good points. I didn't consider a fair scale for hireability....and until I'm able to come up with such a thing then change my opinion to "of course they should be hired."

Often I've seen, and allowed my opinion to be colored by those that make me think, "God damn it...I'm sorry that you carry this extra burdon, but make some kind of effort!"

Thanks for the reality check.

No problem, man. I really do see where you're coming from, and I agree that we have to protect our patients and try to make them as comfortable as possible, I just have no idea where the line is drawn or how we could decide on it fairly in such a way that no one else's rights are trampled on in the process.

Personally? About 38%. Service-wide I think around 28-30%.

EDIT: That's ALL refusals. Treated no-transport and refusal of all aid.

EDIT 2: We're a county-based third-service (EMS separate from Fire) agency covering a region of urban, suburban and rural locations with a call volume of around 50,000/year.

Yes and yes. One of the folks I most enjoy working with at my service is a lesbian. We get along great and work well together.

actually, I don't believe the question is so simple. Having worked in Trinidad Colorado I've been exposed to many that were living as opposite genders prior to surgery, and very often their passability is far from ideal. Garish makeup, terrible, unstyled wigs, etc. much of what we do is provide comfort, yet being in a place where I was expected to pretend that a man dressed as a woman from a comedy or horror show as unnoticeable made me uncomfortable. Should patients be forced to perform the same mental and emotional gymnastics? I don't think so. My heart hurts for these people, but it hurts also for those too small, handicapped, or injured to do the job, so should they then too be allowed to work in EMS based on my wish that everyone would be allowed to make a living in any way that they choose?

I've worked with gay and lesbians, and currently work on a project populated by 37 nationalities, so it will be tough to make a sentence of bigot or repressive stick to me I think....

If one is passable, then I see no issues, if not, then I see no way to claim that they can truly do the job, as a patient advocate, based simply on their ability to lift as much, or push the same drugs as another....right?

Dwayne, I understand where you are coming from and see your point, but my question would be, how are you going to define what is an acceptable level of "passability" when it comes to transgender workers? I think that adhering to universal policies regarding makeup/jewelry/hair styles is appropriate, but otherwise, is there any other measure you can identify that would be appropriate in determining what is acceptable appearance standards? On another note, this time regarding your comment about how we're supposed to be a source of comfort for our patients, isn't there the possibility of conflict with that goal and other appearance abnormalities? What if someone is especially ugly? What if they have gruesome scars from a previous accident, have an eye patch, have lost fingers or have missing teeth? What if they look like Carrot Top? These things can also be distressing for a patient, and interfere with their ability to be comforted and comfortable, but can we really prevent people from working or dictate appearance standards beyond the typical uniform standards? And no, I don't think you're a bigot, I just want to know how you reconcile the notion that a transgender should be "passable" (and know by whose standard, as gender-specific beauty is subjective and has changed greatly over the years) with other conditions that may make people uncomfortable.

So, this topic isn't so much about whether or not EMS can safely refuse patients (the jury's still out on that one, but seems to indicate that additional education will be required), but rather about whether or not it will actually come to pass. It seems like most of us in the field realize that the current system is broken, and that EMS transport to the ER does not provide cost-effective, evidence-based care to our patients... On the other hand, it seems like I've been noticing more and more people within the EMS community suggesting that even if this is the case, the idea of an evidence-based, cost-effective EMS treat-and-release or release-and-refer model might face another major obstacle... namely, physicians.

Obviously while avoiding unnecessary transport and referring more of our patients to a more appropriate avenue of care might be good for our patients (and their wallets), it would also mean that ER's and ER staff (physicians, nurses, techs) would also be losing money. I'm not sure about your own systems, but I know one of the hospitals here locally is notorious for upgrading just about any patient to a trauma alert, regardless of what EMS's assessment findings are (I literally had a nurse straight up ignore me when I told her that a patient suffering a posterior rib fx from a fall had no injury to his scapula, and she went on and upgraded him to trauma for "scapular pain"). This to me makes me think that at times the hospitals are more interested in making money than giving the patient evidence-based (or even assessment based) care, and I know trauma systems across the country have started to take criticism for their tremendous costs.

I guess my question is, even if EMS can safely demonstrate the ability to treat, will we face opposition from the rest of the emergency medical community that stands to lose a lot of money if patient numbers drop? Could the risk of losing that money lead to ER physicians and nurses working to make EMS incompetent to refuse/treat-and-release, even if we can become capable of it?

Other thoughts?

Ours isn't anywhere as fancy as that, just a cabinet with a key.

Fentanyl and midazolam, and it's in a lockbox inside the truck. Poor access when needed, but honestly I've never felt like patient care was worsened by having to run and grab it.

...fanny packs? Nah, dawg, that ain't for me. I ain't wearin' no fanny pack. Just carry stuff in your pockets.

I usually carry my phone (has my protocols on it), a bunch of gloves, a pair of shears, a drug book and that's it (minus the radio, pager, keys).

Real damage to apply a pretend treatment.

She should sue.

Kat, suicide is considered a sign of psychiatric derangement and a suicide attempt or making suicidal statements is grounds to be placed under a protective psychiatric hold here where I am (and I believe all the United States). It's considered abandonment to leave a patient who is a credible threat to themselves on scene.

Don't agree with it a hundred percent, but it is what it is.

People have the right to make decisions that we disagree with or which go against our professional recommendations, insofar as they are not intent on harming themselves. Additionally, not wanting to live isn't the same as wanting to hasten your own demise (and we can only take people against their will in one of those situations).

I agree with Dwayne that it's discouraging to see people engage in tactics which subtly or overtly take the rights out of the hands of their patients. I was encouraged at one time to not ask patients if they "would like to go to the hospital via EMS" but instead to say "what hospital can I take you to" because supposedly the former might encourage them to refuse while the latter implies that they have no option. It was one of the most disgusting pieces of advice I was ever told and I absolutely refuse to give my mentally competent patients any reason to think that they're not the bosses of the show. I don't even like to use scare tactics, even when I really think they should go. My job is to give them the facts, my recommendation, and to let them make the decision for themselves.

Dwayne, did you consider seeing if the patient would consent to you taking him to his wife or meeting her en route?

Public place means no expectation of privacy. It's unfortunate, but the law is what it is. I think that people deserve more dignity and respect from the media than what they probably get oftentimes, but at the same time I can't condone lashing out against someone who isn't breaking any laws, especially when there are other ways to protect the patient's privacy.

Des is out of the hospital. Her hemoglobin dropped to 5 and she received a unit of blood. It's back up to 7 and she's feeling better so it'll be iron and vit c for a while while she recuperates.

Thanks for all the kind words everyone. Unfortunately it's kinda been out of the frying pan and into the fire. Des had her D&C today and had a good amount of bleeding. They ended up transferring her out after her hemoglobin came up at 5. We're at the hospital now waiting for her to get a unit of blood. Keeping my fingers crossed that shell do better from that unit and get to go home and not have to get a second unit and have to stay.

Thanks again

Thanks guys. Des and I both appreciate it. It sucks, but it is what it is and unfortunately there's nothing we can do about it. Des is going in to have D&C this week and hopefully we'll be able to try again later on.

Sounds like you need to change your protocols, then. Do you at least have sedatives/antipsychotics available to you by standing order to use if you need to?

It sounds like the system isn't working in your area. Protocols, policies and guidelines are meant to make the system work efficiently and effectively; if they're no longer doing that (or haven't ever done that) then it's time to get management involved. How else can you provide the kind of care this patient needs?

I share your frustration and I agree with you wholeheartedly. We should not be treating patients with chest pain with aspirin and nitro; rather, we need to get it into our heads that that is the treatment for patients complaining of ACS.

Not all chest pain is ACS, and not all ACS includes chest pain.

Kaisu, that's pretty messed up. But the only way to combat the anti-clinician mentality is to make that kind of mindset unacceptable among ourselves.