DwayneEMTP

I knew from the beginning that you all were going to ask why, yet believe it or not, though I know that I knew then, I can't for the life of me remember why...I think it was probably because he was afraid that he would be moved beyond the reach of his wife if she wasn't traveling with him. Not an unrealistic fear, though I don't remember if that is accurate or not.

As to making a recording for his wife, I love that so much! But no, I didn't think of it. But will use it in the future. I once pointed to a man's 20 year old duaghter, his EKG showing tombstones, and asked, "Are you ok with your daughter doing CPR on her dead father? That's what you're asking if you refuse to come with us!" And yeah, halfway back to the station we got redispatched and he was dead...

I did use like tactics on this guy, but he was unswayed. He was obviously a threat to himself, but not purposely so. I just couldn't convince him that his life/leg was in danger. Not because he seemed altered in any way, but in the same way as if I was trying to convince him to quit smoking..."Yeah, I know what you think, but I'm going to be fine or die...that's life." Know what I mean?

Dwayne, can you agree that perhaps our current system and culture could use some sort of changing? I'm a 2nd amendment supporter, but I think reasonable interventions such as mandatory background checks and comprehensive training requirements can probably be agreed upon? Clearly, an outright ban will have people drawing lines, but I would like to see some sort of common ground.

This is such a slippery slope for me...

I would love to say, "of course manditory background checks and training make sense..." But those would be managed by the government of course.

In the same breath I would love to say, "Of course a woman has the right to make choices about her own body without govt censur...who could question that?" (Edit: Or, "of course a same sex couple in a committed relationship should enjoy the same rights and protections as any other couple.") And yet questions, and laws, and restrictions there are, right?

Nothing would make me happier than to implement background checks and manditory training requirements for a right to own firearms and be confident that it would stop at reasonable limits, but how can a reasonable person have faith that that is where it will end, instead of being simply a foothold for the govts next 'minor' change? I think the vast majority of gun owners and second ammendment supporters feel the same..

I would be curious to know though, and this isn't my argument, but my cynical side showing is all...how many of the attacks that have happened would have been prevented with those measures in place? (I've no idea of the answer.)

Edit: Sorry for the redundancies...we've been posting at the same time...

Also, my opinion on the intentions of the 2nd Amendment are my own based on very limited readings on the subject. They seem to make sense to me based on my understanding of the reasons for founding our country and what seems to be logical precautions coming from a group of very logical men.

Actually, I was injured/unemployed during the entirety of the congressional hearings of the Waco mess, and there was never any evidence that anyone was held against their will, as testified to by the undercover FBI agent that had been living with them for the previous 6 months and more....

But, maybe that's beside the point. I'm not clear on why the Fed Govt having little to do with you has bearing on whether or not we'll someday need to defend ourselves against a corrupt govt, either local or federal? Or how it applies to gun control issues?

And to Chbare, though the drafters of the constitution may not have seen assault weapons, they would likely have drafted their documents with the idea that the people would have weapons in line with those possessed by the govt, right? And in that regards it seems the relativity hasn't changed much, except that the govt has weapons much more sophisticated now...

I'm not sure why you consider that a mockery?

Our country was founded specifically because our forefathers felt the need to run from a repressive government in a country that was careful to keep them powerless, and then had the wisdom to try and create a new society where they had learned from that and attempted to disallow themselves from ending up in the same situation again. That just seems prudent and intelligent, doesn't it?

Also, not having been raised in that culture I can understand where you're feelings come from. I have just as hard a time imagining living in a place where I'd ever be comfortable trusting in the good will of my government to always "do the right thing." Though, I've heard that your government might have one or two issues of your own.. :-)

In my country being a resident of the Land of the Free comes with a responsibility to be prepared to defend those rights.

I can no more imagine putting myself in a position to need to beg my government to preserve my rights than you can imagine having to defend yourself against yours...maybe it's a gap we'll never really be able to bridge.

He's unwilling to leave the place where he was injured unless his wife takes him.

Pt shows all of the signs of being a heavy 'off shift' drinker. Thin, sinewy (?), wrinkled face, yellowed nicotine teeth, but also all of the signs of a serious, life long responsible bread winner.

No signs of drugs/alcohol at this time, pupils are PERRL at 3cm, speech is clear and appropriate.

Two far from my area of response responsibility for me to stay with him. Lone medic slot so no one else to cover. Only Local National staff available and they're not qualified for me to hand off to.

Pt refuses IV, and I considered snowing him, I really did, but couldn't justify it morally or ethically.

This is an actual patient/scenario of mine. It happened in a Non American country, though in an environment where the moral/ethical/legal rights of the patient and responders are pretty much the same.

Going into this I'd ask us to proceed accepting a couple of assumptions as fact, in the spirit of the intended question. The first that I am at least minimally competent in assessing a traumatic patient, to include an accurate assessment of mentation. The second, that I'm at least minimally competent where getting difficult patients to bend to my will is concerned. In other words, even if you don't believe me competent in those areas, please don't take the easy way out, ("You couldn't do it, but I could have.") in this discussion. See what I mean?

You're dispatched by the comms shack to a 'man with a hurt leg."

Upon arrival you are pointed to a man sitting on a stack of pallets, he's calm, smoking a cigarette, and in good humor. He answers questions quickly, clearly and appropriately. He is aware of all that is going on in his environment, his balance as he sits there is confident. If you could see him from the knees above only there would be no sign that he has any issues at all from your initial impression.

Below the knees however you notice that his left lower leg is being held in place by a 2" diam piece of of lateral skin, the distal lower leg swinging freely. Evidently he's the driver of a truck that's come to pick up some rolls of steel cable. While directing the forklift one of the forks traps his lower leg between it and the palet, effectively amputating the lower limb. The injury is approx. 20 minutes old at this time, bleeding seems to have been limited by the fact that the leg was separated with a crush more than a clean cut, there is very little active bleeding at this time. Sandy/gravel conditions make it impossible to estimate blood loss. Pt rates his pain at 3/10 while looking at his leg and swinging it in little circles as he smokes his cigarette. His only real concern is whether or not it's care will queer the vacation plans that his wife has worked on for two years, set to commence in the next two weeks.

While my partner goes for the cot (trolly, gouney, etc) I lay the patient down, got a good set of vitals, packed the stump with gauze, lined up the lower limb, smashed it into the proximal packing, and tried to hold it all together with a SAM splint and elastic bandages.

When the patient sees the cot coming he immediately says, "I'm not going with you! My wife will be here in a couple of hours, I'll have her take me to the hospital. I'm not going with you, and we both know that you can't make me."

Vitals:

B/P 136/96

P 98

SPO2 99% r/a (sea level plus smoking)

Skins p/w/d

L/S full all fields with only the expected dispersed light wheezing common in chronic smokers.

Described injury the only discovered or reported. Hands/knees/elbows atraumatic.

No n/v, dizziness, drugs/alcohos reported nor suspected.

Unfortunately I've cared for the wound in a rudimentary fashion before the discussion of transport becomes an issue and the patient is convinced that it is more than satisfactory to keep him well until his wife can transport.

I use every argument I can think of up to and including loss of limb and death, even my tried and true, "if you have anyone that you love, or loves you...anyone that depends on you to be a man, then you have no right to act in such a foolish way!" but none so much as makes a tickle in his resolve to wait for his wife. I call his wife, she's two hours out, explain to her that I need to take him now, she talks to him for 5-10 mins, but he won't budge.

I've never really been exposed to such a patient before. I'm comfortable making the argument that he was mentating clearly despite being nearly uneffected by the severity of his wound. Those that have worked around the old time farmers or cowboys can maybe picture this patient...You'll just have to take my word for the fact that you can not legally make the argument later that you took him against his will due to an altered mental status. (You can probably make that argument later and succeed with a CYA tactic, but you can't truthfully make this argument and pretend to stay moral and ethical.)

What do you do? Do you fill out your refusal and leave him? Can you justify this in your service later? If you choose to force him into the ambulance, what legal powers do you use to justify this? What are your moral and ethical responsibilities here?

I look forward to your thoughts...

Whenever this debate pops up, people bring up other objects that can be used as deadly weapons such as the ones Mike mentioned. The difference is these other objects have nonlethal purposes. The only purpose of a gun is to kill, whether it be for hunting, personal protection or a killing spree.

One argument that I find laughable in these debates is the one that a person should be able to protect themselves from the government. First, the government can't pull off something as simple as breaking into a hotel room to spy on someone. There is no way they are ever going to be competent enough take control over an entire country. This plan also depends on the members of the military to be conspirators in the whole thing. There is no way you would every get that many soldiers, sailors, airmen and Marines to turn against their own countrymen. The final thing, if this take over ever did get successfully organized, the battle was lost years ago. A person's AK-47 or whatever semi-automatic they prefer is no match for tanks, bombers, fighters, submarines, etc. The government had you outgunned decades ago and if they really wanted to kill you, they could have done so already.

I actually find the fact that we may need to defend ourselves from our government the least laughable of all of the arguments. I would hold out Waco, TX as a perfect example of that. That slaughter had a mish-mash of nearly every law enforcement agency in the U.S. involved in killing men, women and children accused of no crimes.

Not only did they all participate in attacking American citizens, they did so with zeal, and in the end were ok with the fact that they murdered them all in cold blood. Can there be a clearer example that our government can't be trusted to protect us when they believe that we're unable to protect ourselves? (Before making the argument that the government believed they were going there to confescate illegal firearms, reference the question asked by Sonny Bono during the congressional hearings, "Do you normally approach a compound that you believe houses illegal .50cal weapons hiding inside a horse trailer covered with a plastic tarp?") All of those people killed illegally and, to the best of my knoweldge, not a single person went to jail, or even lost their jobs.

I'm truly surprised that these killings continue to be part of the anti-gun debate. These crimes are being committed using guns because guns are the golden ticket to the lead story in the news, in my opinion. Take way my guns (I'm not a gun fan, though I own two handguns), and instead I'll simply drive my truck down the school sidewalk as children are waiting to be let into school. Instead of shooting a theater full of people I'll throw a five gallon pail of gasoline over them followed by a zippo. My body count will likely be much higher. Plus, what do you suppose the odds are that the next hundred people needlessly killed will be killed with vehicles/gasoline instead of firearms once I've made front page news?

I saw a poster on FB recently, one of those with Willie Wanka (The real one) that said, "So making guns illegal will take them off the streets? How is that working for Marijuana, Crack and prostitution?"

Though you may label me as a fanatic, I do truly believe that within the spirit of the Second Amendment is an ability to protect ourselves against our own government, and that need is as relevant today, again in my opinion, as it was then, perhaps more so.

[Edit: Posting this as Justin posted it on his FB page as well. I'm not revealing a confidence.]

I'm going to post this as I'm guessing Beibs has other things on his mind...

The lastest visit to his doc showed that their child had miscarried...

Love and thoughts for peace and healing to Des and Beibs during this terrible time, from the Womacks in Colorado..

Dwayne

Unfortunately Brother, this is going to get you some negative responses as it shows that you're simply another guy wanting to ride a fire truck but has to pretend to know how to do basic medicine to do it.

Most of us here take medicine pretty seriously, so questions of "What's the cheapest path, with the least amount of actual work that I can take to get a cert that allows me to brag about saving lives??"

I'm truly not trying to bust your chops, just explaining that you'll need to be a little thick skinned in this thread is all.

To the best of my knowledge there is no place to take it completely online, but we have a few here that have done the didactic online and claim that one of the schools is pretty good..though I can't remember the name...

They'll find you here though and help you out.

Good to have you here...have a good day!

Hey! Welcome to the forums....

We sometimes bash on hosemonkeys, but as far as EMTs, until they start the "Paramedics save lives, EMTs save paramedics" nonsense, they're pretty safe.... :-)

I think that you'll like it here if you really want to learn...feel free to jump in. Even the replies that you don't like are coming simply from an internet forum...they're not terminal..

I look forward to your thoughts!

Fair points from everyone...

[Edit] And Mike, I have no doubt that you are in fact creative enough to do so. I guess the parts of your posts that get under my skin a bit is the static nature of the thinking, at least to the way that I read them. "We can't do that because...." Add, "yet" and I'll have a much easier time leaning over to your side of the fence.

Like Chris mentioned, it's a culture, and as with any culture changes need to be planned, and nurtured, and that's just not happening in many places I think. Not because it's not doable, but because people are comfortable with the pathologic way that things are, and have always been. And that kind of thinking, in any area, just gets my back up...

The more open system works, it's nurturing and productive, all of the steps down the path have been laid out by others over the last 20 years, but implementing it just hasn't become easy enough yet for most. They're all waiting for directions to the trouble free, pain free path. That, of course, is unlikely to ever happen, regardless of the provable benefits.

If a systemic culture and policy exists where people are comfortable with being singled out, I could see such a process working; however, this is something that would need a specific policy in place that has passed by the legal consultants and is part of the larger culture of a company. However, shoehorning something in is bound to lead to disastrous consequences, especially in companies that have a strong union presence and like involve union representatives and contractual obligations when it comes to these situations...

With th that said, in a situation where somebody may make a sentinel event or error, it is your duty to do something about it. However, following an event or potential event, nothing good can come from finger pointing and singling people out in front of a large group of people....

Agree completely. I don't disagree with the snipped sections, but am only trying to be brief.

I get frustrated with the, "Yeah, this can't work because...." arguments, though I don't mean to imply that anyone here is using them, because I've seen these systems work, and work so much better than traditional models. But you are absolutely right.

On the Developer I can't imagine there the situation where a rouchneck would have been laughed at or scorned for making an error, but the vast majority of the crew would have been angry to find that s/he'd tried to hide it. The attitude being, "You're smart, and that happened to you, and yet you were going to remain silent and let me make the same mistake someday?!?!"

At the time that I was there their production stats were through the roof, as well as their safety record, and they'd been over 6 years without a lost time medical incident....amazing. I love working in the culture, but it's one that they had to dream of, and then invest themselves, each person as well as the company, to develop, no one gifted them with it...

I've tried to follow that model here, where "face" is everything...it's been difficult, but amazingly satisfying....

Again, it's crazy to wait until a problem is sytemic to identify it and try and mitigate it for the future...If one person's had the issue, it's likely another has already as well and simply hasn't admitted to it, or that another will have the same problem in the future. Why not take every opportunity to resolve small issues...why wait until they become larger to learn from it?

But again, it appears that you will continue to restate your feeling that a single person issue should be dealt with in private without really making any effort to show why that belief is productive either to the individual or the group, but instead only to an organizations HR manual.

Because that has been the context of the conversation up to this point.

And not any personnel issues in general, we've been discussing errors in particular.

If the process is not punitive, then why is it not used to the full benefit for the learning opportunities possible for all?

The fact that you've always done it that way more makes the case for it being more likely archaic, not less.

I've owned two relatively successful businesses that used learning instead of punishing significatly and successfully in their management practice.

In each place that I've worked the remote medic has a supervisory role that has to interact with the HR dept, so I'm aware of the rules, but don't agree with them more because of that. In each of my current gigs the medic is tasked with improving the performance and competency of the staff. My biggest struggle here is to get people to celebrate errors instead of hiding them. Why? Because the system that you love, accept (wasn't trying to be intentionally irritating) has been in place in these environments for far too long...

On the Maersk developer, while leased/managed by Exxon/Mobile certainly one of the most successful companies in the world, there was no punitive action, ever, for a first time error. And each error was brought up in the company safety meeting at the beginning of each shift complete with the names of those involved, as those involved almost always brought the error to light. Those making the errors were considere very productive for their honesty, both by management and crew, and the new information that they brought to the team to help everyone avoid making the same errors in the future.

Read the book, "Straight from the Gut" with Jack Welch, considered by many to be the most successful business manager in American history and he makes it very clear that removing any punitive measures from errors, and making the exposure of errors to everyone laudable, is largely responsible for taking GE from bankruptcy to one of the most successful and powerful companies in the world.

The only realistic argument that you can make for the practice is that it plays out better for some companies legally. There is no argument that I can see that you can use to defend that it's not archaic and counter-productive. It's just simply too well proved to be so...

I think that where we're looking at it differently is you guys seem to see the addressing of mistakes as a punitive issue always. And I don't really. In fact, unless someone has been purposely lazy or simply morally/ethically corrupt, I think that no mistakes need to be punished, but instead learned from. This attitude also makes it much more likely that people will admit and try and mitigate their own mistakes in the future...

I was recently in a Safety meeting where they'd discovered that a few weeks before a critical screen had been damaged by a boulder. No one reported it and it ended up in that whole machine being dmaged and shut down, as well as the entire mine process, for nearly two weeks costing millions of dollars. They were discussing how to prevent this from happening in the future. At the same meeting it was brought up that a man had accidently backed his truck up into a wooden pole in the dark. No significant damage to the pole or the truck. He'd parked his truck and reported it, as he was supposed to. It was decided at this meeting that he would be terminated for not paying attention, and then immediately the conversation went back to "how do get people to stop hiding their mistakes?"

I said, "Wait! How can you not see that you can't terminate the truck driver? He did exactly what you're wanting everyone to do and you're going to punish him for it? Does no one else think that that's a little bit crazy??" But they did it anyway, and the cycle continues...

The same in the EMS workplace. Employers say, "We need to discuss and learn from our mistakes. We need to be honest and open about them so that we can all improve." But then when a mistake is discovered it changes to, "Come into my office, we need to deal with this in private."

Does no one else see the counter productive inconsistency here?

Some of the most productive learning moments in my career have been when going into the ER having made a mistake. I'd say, "Doc, this is what I did...Sorry." and later, when there was time the doc, with only one exception that I can think of, would come and say, "So this is what happened, this seems to be your thinking, this is the path that would probably have been better, do you see that?" Very productive...Now, that's not been my experience very often when reporting mistakes to ER nurses, but with Docs it's almost always been positive and productive. Why should our daily workplace be any different?

If your example is to be used Mike, that is a weakness in the punitive practices of the service. There is no way that publically discussing mistakes changes the consistency of those practices, only makes them public. If you're afraid of people seeing your decision making processes in public then perhaps the issues lie in those policies instead.

I can see no way that I can give management permission to air my private issues publicall that would give them legal issues in the future. Though I've admittedly not worked in any services at politically charged as those that you have. Maybe that's where our difference of opinion lies?

You're probably right Mike, though I don't see how anyone is opened to liability as long as HIPAA/Pt confidentiality is respected.

And I don't think that I've personally added the negative connotations at all. Things that you are ashamed of you deal with in hiding, things that you aren't you deal with publically. I don't see where that's even a little bit of a stretch.

DFIB, if we use this definition,

See, I hate the correction in private, unless someone is getting a written warning/termination level correction.

At the last service I worked at in the states I screwed the pooch on something and was called in and we discussed it. The next time that we had a full crew meeting I brought it up and mentioned what I'd done, why, and what my thinking was after our meeting. I thought that the supervisor was going to have a stroke! His face was all red, he looked really nervous, because I'd brought up our private stuff...but it was an honest mistake, and an excellent learning point.

At the meeting I said, "From now on, I'd like all of my private meetings to be held in public where everyone can learn from them. I give everyone permission to say what you think out loud in front of everyone.." and immediately was told, "That would not be appropriate..."

The thing I hate worse about non serious offenses being taken care of in private is that it help propogate the negative stigma attached to mistakes, instead of celebrating them as parts of life and EMS, it says, "You made a mistake...let's hide your shame behind closed doors..."

Yikes....chin up Brother...

Sending thoughts for strength and patience from the Womacks in Colorado...

(Edit: Creating my post at the same time as systemet. Redundancies are accidental.)

I feel like the health of the patient should have priority over everything else, including seniority.

And you would be right. But in these situations, the family is horribly traumatized most often, so when working an arrest in front of the family they should be considered patients as well, assuming that you have the time and safety to consider such things.

This is a valid question from the point of view that having an argument in such a setting can forever leave the question in their minds, "Was everything that could be done to save my loved one done?" "Did they do the right things, or did they screw up?" "Why couldn't my son have gotten one of the brave, professional teams like I see on TV? Would he have lived if they'd not been arguing??" I've no interest in the legal implications of such things, but for a family that's just had the horrible image of their loved one being molested by people doing CPR forced into their brains forever, adding to that in even a tiny way is a huge deal to me and should be considered a massive failure by any team.

Jay, though I'm a big fan of you, this thread, and your participation, for me a huge part of EMS is respecting those that came before us, if they deserve it, and being grateful to our betters for taking the time and giving the attention to teach us. Both are categories that ArticKat fits into solidly where both you and I are concerned. His statement was prudent, despite you're being offended by it. I would be curious if, after rereading it, you are happy with the tone that your reply was created in? Being snippy and arrogant in the face of someone that's been a really important member of the City and EMS familes for a long time doesn't look good on you my friend....

And yeah, man, I think that this is a question that should absolutely be taught, and even practiced thoroughly, in basic/medic school.

Right!!! How is that possible?? Is this some kind of new String Theory math or something?

In my world, a static conversion should convert both ways....that should be the rule from now on.

Those are friggin' hilarious!

+32 degrees

Distilled water freezes.

Lake Superior's water gets thicker.

Gets thicker? LMFBO

You know, I'm really weak in math...but does anyone know why when you get below zero when comparing F to C that the values are different than when you compare them above zero?

For example, while flying back into country this time, at one point I was looking at the flight data on the little TV screen and it showed something like, Temp- -45F/-42C They shouldn't be so friggin' close together!!!

...I felt this scenario was black-and-white enough to keep the focus clear; when is it inappropriate to challenge the medic in charge, and at what point does the risk to the patient outweigh the risk of losing the confidence of the family or seeming unprofessional in the public eye?

This question is just stuck in my head. I can't begin to tell you how much I love it, as it represents the very best of the EMS spirit in my opinion.

It sticks not only because I love it, but because despite thinking about it almost constantly for the last 24hrs, I have no idea how to answer it. Since my first paid day as an EMS provider I've been a paramedic, so I don't really have much context.

I once disobeyed several orders given to me by a doctor that I know, beyond any doubt were dangerous and possibly terminal to my patient, but I just did it. I was alone in the back of the ambulance, I had no question whatsoever that I was given really bad orders, I knew beyond any doubt that calling to get them changed wouldn't get it done as he'd continue to insist that I follow his instructions, so I just didn't call. I changed to my treatment path, things worked out as I'd hoped, I reported the instructions given to me and my reasons for disobeying them to the recieving doc, and they, I assume, took over from there.

The perfect way to resolve your question involves perfect timing, a great approach to the correction, aggressive enough to be heard but not so aggressive as to be ignored, a strong justification for your recommendation, and a medic that's open and willing to hear it all. Yeah man, depending on the medic you're working with, you're likely screwed... :-)

This statement resonates with me, once again from systemet, "If I worked a shift and was allowed to make an error this big, when someone there could have spoken up, I'd be pissed...."

Yeah, me too...As he mentioned in that same post, one of the things that I'm most afraid of is making a preventable error because I'd forgotten something, or was distracted. I will never, ever thank you for watching that happen while you stand quietly by.