Bieber

The joy of knowing they've helped the real heroes to get better at putting out those handful of major fires per year.

Here's a question for everyone, when I'm referring to patients, sometimes I'll call the men "partner" and the women "dear"... It's a bad habit I picked up from my partner, and even though it's meant to be endearing, but I can't help but wonder if I might be being unintentionally condescending, especially to the women. Thoughts? I still use "ma'am" and "sir", and I've only ever had one patient complain (but she complained about everything, so maybe that was just her personality). Maybe this is more of a "patient by patient" basis kind of thing. I usually do it more with the older patients.

Good on you for standing up for your patient's rights, brother. Honestly, I'd have done the same thing. I don't think I'd've been able to be as nice as you when it comes to that nurse, though... My tolerance for being disrespected by other medical providers is pretty low, especially nursing home staff.

"Her daughter has POA and she says (this is true) that you had better get her to the God damned hospital right now!!!"

"Sorry, ma'am, but I don't take my orders from you or your doctors, and if you don't calm down and please go away, I'm going to have to call the police on you for interfering with an emergency responder." Cheeky grin.

And you can pay the $325.00 bill by cash, cheque, or money order. Credit cards are not accepted.

Nope. No charge without transport. Form is just the refusal!

To the staff: "Thank you for your help, we'll take it from here. Please give us a moment alone with the patient." Then let's give them a look to please gtfo.

To the patient: "Did you have any problems at all tonight? Can you think of any reason why they would think that you were having these symptoms? Also can you tell me your name, where you're at, the date and approximate time?"

Pt appears normal to me now. No noticeable facial droop, stroke scale negative. Pt claims that she had to pee, went to get out of bed, hooked her foot in a blanket and sat down hard on her bottom. She states to having no pain from the fall, there are no apparent injured visible or to palp on her rear, hands, elbows. Her only complaint is that it's almost 1:00 am and she would like to be allowed to go back to sleep. She needs no assistance other than to be left alone.

Hm. Let's get a better description from staff on what they saw.

HR 86, BP 146/88, SPO2 96% r/a, BGL 97.

Not terrible. A little hypertensive.

Do you mean a better PMH/MEDS than no significant history or medications? :-) NKDA.

Doh! Reading fail.

So basically what we've got so far is a possible TIA. Depending on what staff describe and how credible we can consider their findings (considering they did no further assessment and the possibility for environmental issues having skewed their initial findings (i.e. lighting, etc)) I'd recommend further assessment at the hospital.

Time last seen normal? Was the patient like this before they went to bed? I also want to ask the patient when this all started... if they woke up with the symptoms or if they woke up and THEN acquired the symptoms, or if they had them at all before? What time did the patient go to bed?

Let's also do a stroke scale, check her head for any injuries related to the fall, and get a set of vital signs (HR, BP, SpO2 and BGL).

Can we also get a PMH, meds, and allergies?

Thanks.

"It looks like you just stubbed your toe. Let me get you an icepak then we'll have you sign something and we'll get out of your hair."

Welcome to the forums!

"What's up?" / "What's going on today?"

It actually wasn't the medical procedures or necessarily the call types that ruined it for me. It was the uber hero complexes and the incredible amount of angst that made it unbearable. I felt like at any moment someone was going to grab an American flag, run up onto the top of a ladder truck's ladder, and swing it around while they blast "Proud to be an American" to the backdrop of explosions roaring in the background, and end it all with a single tear drop falling down the supermodel firefighter's cheek.

12 lead and 15 leads are used to rule out certain kinds of MI's. There are studies that say one incidence of hypotension can dramatically lower survival rates in certain types of heart attacks. Nobody below a paramedic is allowed to give nitro in our service anymore for this reason You need to know what kind of heart attack is going on if you can.

That's interesting. So EMT's aren't allowed to give a treatment which patients can give themselves?

EDIT: Another question regarding this point... what does your medical director say in response to the fact that, elsewhere in the country where EMT's can still give nitro, there does not seem to be a mass of deaths from EMT's giving nitro? And exactly what is the environmental factor there in Rural Kansas that makes EMT's giving nitro much more dangerous than EMT's elsewhere in the country?

Also, I'd do 15lpm by NRB because the pain is caused by heart muscle dying due to lack of oxygen.

Couple of questions...

If it's a thrombus that's obstructing blood flow to the region of the heart experiencing the MI, how is oxygen going to get around that? It's not a thrombolytic, you know. Also, if they're already sating >/=94%, why do they need additional oxygen?

Aspirin is an anti clotting drug. It will help stop any NEW clots from forming and doing more damage.

And some kind of pain medication would probably also be lovely from the pt's point of view. I'm not totally for sure if this is all correct, but then again, I'm not a paramedic either

I think you were correct except for the suggestion of oxygen for an MI. =)

Watched it. Awful. So awful.

I suppose another question to ask might be? How open is your service to protocol deviation? Do they expect their paramedics to think critically or to simply follow protocol to the letter?

Ok first off I take no offense but I think people are reading to much into my answer. I am an ex cop and ex PI, I have worked with the law and know the law. I am very well aware of consent. However I feel that people are treating this as a "emergency" call which it is not. Look at the facts.

You keep bringing this up and I'm still not sure what you're trying to get at. A call is a call.

The patient is in a SNF. Now it has been my experience that most patients in SNF's have medical issues that require constant care and they cannot care for themselves. What documentation is in the patients file regarding their mental status? Do they have a Power of Attorney. This is NOT a 911 call.

What does it matter whether or not the patient has a DPOA, that doesn't take effect until the patient becomes incompetent. Also, still not sure what your fixation with this not being a "911 call" is.

Involuntary Consent can be applied when dealing with a mentally incompetent individual. Further, someone has ordered this evaluation. The order either came from a doctor or a court. At that point the liability is on them, not on me or my agency.

You assume liability for your actions regardless of who ordered them. Thinking otherwise is the same as saying you would have no liability for performing heart surgery under a doctors orders. Furthermore doctors authority is limited by the law. Just because a doc gave you an order doesn't mean it's legal or that you give up liability by performing it.

The "van" the patient was alleged to have jumped from was most likely an "official" transport van. Likely some sort of paperwork would have been generated on this incident. This is an indication of the patients' mental status. A reasonable and competent person would not jump from a moving vehicle. Likely, this is the incident that prompted the order for the evaluation.

Just because someone jumps out of a vehicle that doesn't mean they're a psych patient. There could be any number of medical causes for that behavior.

Not every "psych evaluation" is used to determine if someone is incompetent. More often they are used to determine if a person is competent and mentally stable.

Not to be a stickler, but you just said the same thing twice.

It is in WA State Protocols that we can transport a "behavioral emergency" (which this would fall under) against their wishes IF we gain consent per local protocol. A doctor's order or court order would constitute consent and would suffice.

Doctors can place competent, non-suicidal people under arrest in Washington?

As I mentioned prior, this patient would be transported and it would be legal for us to do here in WA in this situation. Patient would be placed in 4 point restraints and transported for a mental health violation.

Paramedics can place competent, non-suicidal patients under arrest in Washington too?!

If this was a 911 call and NOT an order for eval, then I probably would not transport unless circumstances presented themselves to indicate patient was not mentally competent.

I guess they must do things differently in Washington, because no where else that I can think of can doctors or paramedics take people against their will without either a court order or without the patient being in protective custody due to suicidal ideation.

Bottom line is the mental health eval was ORDERED by a competent entity (doctor or court). We would be protected under RCW 71.32.170 if we transported this patient. In fact we would likely be guilty of negligence if we didn't transport him.

That's crazy to me, man. Seriously, I can't believe that physicians are allowed to authorize the involuntary commitment of competent, non-suicidal patients who don't present a danger to themselves or others.

Understanding and interpreting your State law will keep you out of trouble. It is not Kidnapping.

Maybe not in Washington. I know I couldn't do that here, though.

Johnson county is still Med-act and Wichita is served by a county-based third service.

I don't know about Kansas but in NY we have what they call Certificates of Need. They are issued by the state to ambulance companies and they define the territories that they cover. The company that I work for in Chemung County hold the CON for the whole county and for the northwest corner of Bradford County in PA and the northeast corner of Tioga County in PA. We contract out the eastern most part of our county to Greater Valley because they are much closer to those communities than we are. Because of this both companies have to be dual state certified.

There's actually not a lot of private EMS in Kansas, surprisingly. EMS here is usually county-based, third-service, although there's some municipal-based EMS services, a handful of fire-based services, and Med-Act (though I think they're a trust?) in Johnson county (Olathe) and AMR (but I think they're just in Topeka). I know the counties to the north and south of mine are a little odd in that there's no one county service but a munch of small little municipal services, although even we have like, two municipal services in our county as well for some of the small little towns way out there in the boonies. My service doesn't usually end up interacting much with other services unless we're providing ALS intercept for one of the small volunteer BLS services.

Alas, a lot of services in Kansas are still using 10 codes, although we're moving away from it.

To the OP, sorry to hear about that. Sounds like somebody was just wanting to flex their muscles and prove who the bigger and badder service was. Did your director ask dispatch the reason why dispatch was disregarding you guys? Or did he just assume dispatch had no clue what they were doing and shouldn't have done that? If the latter, that was a preventable error that could have avoided drama (assuming dispatch was able to explain the situation).

Additionally, it sounds like first responders were on scene. Since I'm assuming they were BLS, they could have given a quick triage and helped with determining what resources the patient needed.

Ok, first of all he has doctors orders. Because they are calling for an ambulance for the transport that tells me he is already confined.

Not trying to talk down to you or anything, man, but I gotta say, that kind of mentality seems dangerous as hell to me. Maybe it's just me, but I don't trust anybody to have done anything unless I was physically there and saw them do it or can confirm it for myself (except for my partner and the other folks who work for the same service as me). In a perfect world medicine would work as one cohesive, fine-tuned machine but the reality seems more like everyone is only out to do what work they have to to protect THEIR liability, and everyone else (especially us "non-medical" transporters) will just have to worry about themselves. If he's alert, oriented, non-suicidal, and otherwise competent per my assessment, there's no way in hell I'd do anything against the patient's will unless I either have a court order in hand (for me to keep) or a cop present telling me the patient's in custody.

Maybe I read too much into what you were saying, and if so I apologize for sounding like a douchebag, but I just know that I've seen just how little anybody else in the medical world is concerned for covering your ass or making sure that you've got all the stuff you need to avoid being on ass end of a patient encounter. Anyway, the point I'm trying to make is to take everything EVERYBODY tells you with a grain of salt, no matter what organization they're tied to or the letters that come after their name--if you're not already doing that.

Second, he jumped from a moving vehicle on purpose. That to me indicates suicidal tendencies.

Well, we know he's a diabetic. How do we know that wasn't the cause? Or maybe his labs got all jacked up from the last time he dialyzed? And what exactly do they mean when they say he jumped out of a moving vehicle? If he's a nursing home patient, he's probably not able to get around all that well, so how did he manage that feat to begin with? Finally, just because he was suicidal a couple of days ago doesn't mean he still is. Did he get sent in for eval the day of the incident? If not, why? And if so, what was the conclusion? He's back at the nursing home today, so did they determine he was mentally okay? Again, not trying to bust your balls, but if we just assume that the situation is as the nursing home staff describes, we're putting an awful lot of faith that they have done their jobs and done their jobs correctly. And we weren't there to watch them do their jobs. We weren't there to see if they were swamped with patients that day and didn't get much of a chance to do a thorough job; if they were just having an off day themselves and didn't do a great assessment; or if they just always suck at their job.

Third, he is a Psych patient. You would be hard pressed to find anyone that would label someone going into a psych eval as "competent." Obviously, there is a behavior that has been demonstrated to indicate to healthcare professionals that he needs further evaluation.

The nursing home staff said he is a psych patient. They're not the emergency medical providers. The only question we should be asking ourselves is, what do WE think is going on with the patient today?

Anyway, don't take anything I say personally, and maybe I'm off base here and someone can kick my ass back in the right direction, but I try to approach nursing home calls like any other emergency run. I don't assume that anybody there is competent to give me any sort of information that I mustn't temper with my own findings and judgment, and to a degree I kind of go into every call where I'll be dealing with other medical providers with the mentality that every one of them is out to feed me misinformation, skew my judgment, and harm my patient. Never with the idea that I can trust them to have done everything exactly as I or someone I trust would have, with my liabilities and responsibilities in mind, nor even the highest standards of patient care. Maybe it's wrong, maybe it's not.

I don't know. Either way, hopefully this gives you something to think about.

If there's no court order and the patient hasn't made any credible threats to harm himself or anyone else, nothing I can do about it. Sign here, have a nice day.

As an aside, we don't take orders from on scene physicians.

I have my associates in applied science and I'm currently working on completing my bachelors of health science with an emphasis in paramedicine.

I've actually read a lot about this (I'll admit it, though I'm terrible at math I'm deeply in love with quantum physics), and like Chris said, particles aren't actually aware, but their nature is definitely curious nonetheless!

If you haven't read about it already, read up on wave function collapse and the Copenhagen interpretation. There's a ton of great videos on youtube as well about physics (Khan academy is a great educational channel). Another really mind-blowing thing to learn about is special relativity (how the very nature of light can cause the universe to shrink and expand).

Good on you for learning about something new, brother.

Not really an issue for us where I'm at. We regularly leave non-disposable equipment at the local hospitals and we very rarely transport to hospitals outside of our service area (we have two level one trauma centers here, so except for the occasional non-serious patient who can be handled by one of the more distant facilities (and who requests it) they pretty much all stay in town).

The hospitals even decon our boards and splints for us!

Febrile with hypotension and a known infection meets the criteria for sepsis. Pedal edema could be due to decreased mobility (due to the illness) and/or worsening right sided heart failure due to increased pulmonary resistance secondary to swelling (not confirmed cardiac history, but a previous history of diabetes and smoking puts her at increased risk for it). Sugar's high, but given her history of uncontrolled diabetes it may be due to that or just due to poor glucose homeostasis secondary to the infection itself--I'm betting on the latter. Given the severity of her illness, I don't think we're seeing BGL levels high enough to be the causative factor here.

Let's decide to either start working her here or get her out to the truck so we can get a line and start pumping some fluids into her (given the family's emotional state, the truck might be better).

You said lung sounds were coarse? Are we talking rhonchi or do we have any wheezes in there? If signs of bronchoconstriction, let's try a duoneb; otherwise let's titrate our oxygen up and see if we can improve her oxygen saturation to ~95%. Wherever we go, let's try a liter of fluid for now and reassess.

Also, can we find out what antibiotic she was on? Might give us an idea whether or not the doctor who diagnosed her had identified a causative agent or if she was just prescribed a broad-spectrum antibiotic for pneumonia. What facility was she seen at when she was prescribed the medication? Was it a hospital or a primary care setting? If a hospital, we'll want to take her back to that facility if possible.

Yes. It was a real struggle for me, but I actually had to stop being quite so awesome.

=D

Lol, no but really... I'm developing a reputation for being an arrogant asshole. Which I probably need to change (see, definitely), although to be honest I'm not very cognizant of the things I do or say that have given me that reputation (at least, not at the time I'm doing them). It might in part be from taking so much initiative at work (i.e. submitting proposals, etc), but probably mostly just for speaking my mind to much (see, no brain-mouth filter).

I don't know. I'm sure I am an arrogant asshole, and more than a little narcissistic (along with a multitude of other personality flaws)... If I could be a more likable person I would, but I guess it's easier said than done.