DwayneEMTP

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, pru·dent /ˈpro͞odnt/ Adjective Acting with or showing care and thought for the future. Synonyms cautious - discreet - wary - careful - circumspect Then prudent is exactly what it WOULD be, right? I think that we've continued this tact because of tradition, not because it's at all prudent.

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.) 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!!!

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.

Yeah, there are quite a few things wrong with this scenario as presented... Only three shocks in 30 mins for continuing Vfib? Only one round of Epi in the same amount of time? A decision to transport yet discontinue meds? (Though perhaps with a 30 minute transport, after a 30 minute effort where Epi was pushed properly, it's likely that the truck had no more onboard.) It sounds to me Brother like your friend is making up stories, or else everyone on scene, not just the medic, needs to be removed from patient care as incompetent...Or, maybe this is a question that you had but didn't think that we'd take it seriously if you presented the scenario other than factual. Either way, your presentation was intelligent and thorough, you've been participating completely, so I don't really see how these inconsistencies change the context of your question, and I think that it's a really important question. And, I think that you've gotten some really amazing answers...Great job! To my way of thinking, these kinds of threads are the best of what happens in the forums, and yeah, including the discussions as to whether or not this really happened. Let's try not to derail his thread with other things not pertinent to the OP's real question if we can avoid it...

Yeah, man, what a mess. Fixed that for you... That is the $64,000 question right there. (Sorry if the reference is lost on you youngesters..) If the report says Amiodarone but there was verifiably Atropine pushed, then every effort should be made to burn this person down. You know what Brother, this is a really tough question. But I absolutely love the context that it is asked in. Not only patient focused, but patient family focused as well. This is so important to their future healing... It's difficult for several reasons. First, the fact that your correction wouldn't be welcomed by the medic is professionally pathologic. Like Curiosity said, such a comment coming from ANYONE would have given me pause and cause me to consider my current course of action. I don't know how many times my partners have steered me onto a course of action that I liked better, but it has been many, many times. Sometimes it wasn't adjusting an obvious error, though that's happened too, but just a way that they felt was better, and I could see that they were right. Once on a cardiac arrest I instructed my basic partner to push two amps of bicarb on an extended arrest. One of the First Responders (Very lowest level of care in the U.S.) put his hand over my partners before he could push it, looked at me really intensely, help up one finger...the obvious question being, "Don't you mean one amp??" My partner, ever the professional, wasn't offended, looked to me for clarification, and I instructed him to push both amps. Afterwards the first responder came and asked why I'd made the decision, and I explained that it was the proper dose for such a large patient. These types of interactions should be welcomed by every member of the team. I've often wondered how a medic justifies ignoring the possibility that others might have valuable input that they'd not considered when on every arrest I've ever worked to the hospital the last thing the doctor does is to turn to everyone in the room and ask, "Is there anything that anyone can think of that we've missed, or that they think that we should try before calling this?" If it's good enough for the doctors, then it should damn well be good enough for me too... Sometimes what appears to be an obviously wrong decision, won't be. So where do you draw the line at "I've made my suggestion and it's been over ruled, so now I'll trust that my medic has a good reason and move forward with his/her plan." Or "I KNOW s/he is wrong..I am morally and ethically bound to stand up and defend this patient against this treatment!" I don't know. If you constantly work with different partners then It's difficult to get to the "I trust you even though I believe this to be wrong" stage...I've just never really been in that position. I've been really blessed that any time that I wasn't the lead person on scene, that the person that was welcomed any and all feedback that was delivered in a professional manner. Sometimes, you just have to teach your medic how to be a grown up, and if you can't do that, then sometimes you have to report them and allow others to force the maturing process. It's truly not easy being smarter than you're supposed to be when a lower level of care...And I mean that sincerely...

Thanks guys, but there's no need for sympathy. I just tend to fall into a bad financial category in my country. If I made a third less than I do then I'd probably qualify for govt. sponsored/assisted healthcare, or at least Dylan would. Or a third more and it would be easier to afford what I need for my boy and health insurance also. Also, if we'd choose to have Babs work too, as most American families do, then we'd likely be in a different category, but we can't really imagine allowing someone else to raise Dylan in our absence. I'm not a victim of our system but of my own choices. Most often it's fine, but on rare occasions the lack of options can be a little bit scary. Also, I've been thinking of you the last week or so systemet! I miss you when you're not here! It's my goal this week to try and create some more stimulating threads, at least to the best of my ability, to try and lure you back into the fold... Thanks for participating all...I'll continue to update this thread as I move forward in the complaint processes...

A private plan is possible, but not really financially feasable for us. The least expensive plan that I was able to find was about $14,000/yr, and that wasn't a very good plan. It had a $7,000 deductable per person I think, and almost nothing excluded. A plan that would be realistically usable was closer to $19,000/yr, ($3,000 deductable, basic office visit costs, Dr. referred diagnostic testing, etc and dental maint. excluded from deductable) and though I could pay that, I'd have to take away Dylan's professionals to do so, and that's not a great option. If I was dead Babs could continue to live and pay them for the next 10 years or so...not a great option, but, man...I'm not sure what good options there are..

This is kind of the crux of my interest in this part of the conversation. A Dr. gave a speech in 1972 (according to multiple sources that can be refound if they are important to anyone here) at a medical conference explaining his theory that Rahbdo should be present in these injuries, and it was accepted from that point on in nearly every circle that had interest in such things until, as often happens, it was simply accepted, and taught, as well proved fact, despite there being no studies validating it. I was taught that particularly if a pt has become altered secondary to hanging in a harness sedately, that you lower him into a sitting position, leave the harness in place, transport sitting up, and be prepared to mitigate cardiac arrhythmias with sodium bicarb if necessary. (The reason I've pounded on delivery methods and amounts is that I was never, to the best of my knowledge, taught that specifically, just that I might consider using it.) But it turns out that Rhabdo is almost never, and possibly never, at least in the type of patient described without associated fall trauma, present in these patients. That most of the morbidity and mortality comes from leaving them sitting, allowing the cerebral hyperperfusion secondary to the blood pooling to continue. I actually got stuck on this path after reading a Wiki article on the subject where the incredibly poorly written article explained that the patient should be lay down and treated the same as any other patient altered secondary to hypoperfusion. I'd intended to make the comment that "This article is so misinformed as to be dangerous." but wanted to be able to source my opinion....then found out that I couldn't. One of the articles used surgeries on large muscle extremities as an example. They mention lower extremity surguries where the leg has been tourniqueted (not sure if that's a word) for sometimes four or five hours, with the associated muscle damage and release of cellular contents from the proceedure, yet, the article claims, though it's monitored, rarely is mitigation of pH and/or electrolyte pathologies necessary. (Though, the one or two vids I've seen of these types of surgeries they wrapped the leg from bottom to top very tightly with gauze to force as much blood out as possible before placing the tourniquet, so I'm not sure if this example clearly applies without relevant volumes of blood pooling to reenter circulation??) So the recommendation seems to be for prehospital personnel, at least in the UK and Austraila (the places most often returned in searches when I'm in PNG) that these patients be treated as any other pt believed altered due to hypoperfusion...A, B, Cs... Again, my apologies for the lack of sources. I'd not really intended to post this when I started looking into it, and then, as I'm sure most understand it was an exercise in 'stream of hyperlink' research, so I didn't keep track of when or where I found the things mentioned and won't be at all offended if the comments are discounted on that basis. I've just not had time to try and retrace my steps here.

I knew that it was taking a chance, but cardiac issues are for the wealthy or well insured, they are not really for the middle income struggling family, and certainly not for the single income family with handicapped children. Dylan needs a speech therapist, occupational therapist, has a trainer at the gym. All really, really important to help him participate in his life to the best of his ability and desire. Do you, as his dad, take all of those things away for a $10k cardiac work-up (making assumptions, but, as a clinic visit was a thousand bucks it's probably not far off...) to ease your mind, or try and be more conservative as long as possible when perfusion issues don't appear to accompany the other symptoms...Because there is certainly no way that I can accept that bill and still keep those services. Not whining, or defending really, just explaining my reasoning. I know the choice that I made, but I'm truly curious about the choices of others...Maybe there are options here that I'm not seeing? I've gotten jammed up by being sensitive to those patients that explained that they couldn't afford a huge hospital bill unless I was really certain that they were in danger..that it would be life altering to be transported for tests to rule out issues...and I get that completely, several times having the family drive them when I felt it was likely non critical, and following them to the ER in the ambulance in case I was wrong. It's really easy, and makes us feel good to say, "Where our health is involved money should never be considered..." But real life, for me anyway, isn't like that at all. Every dollar I spend on me means that something gets taken away from Babs or Dylan (figuratively speaking)...And to take the therapists away from Dylan could be life altering for him. (Therapists are wicked expensive, but really valuable.) Sure, losing me would be life altering...but I was playing the odds the best way that I knew how... Again, I'm not whining. I've chosen this career, created that amazing boy, and have chosen, along with Babs of course, to be a single income family. So I'm not pretending to be a victim of the system, just explaining that for me there really isn't a realistic system beyond basic medical needs. Significant non emergent tests and treatments are for those well above or below me financially. If this was your (speaking to all willing to participate) issue, all family, age, financial, historical issues as described in this thread...what would you do?

Thanks for that guys...I'll contact them...I'm pretty committed now to not only messing up the doc, but also the clinic. All had the chance to do the right thing, and all have chosen not to...so, game on.

Go ahead and take a look at suspension trauma/issues...let's see if what you find surprises you in the context of this discussion...

In theory you were on the right track...whether or not the theory is valid is up for debate... :-) (Edit: in reference to Kate, was posting at the same time as Curiosity.)

Yeah, that's kind of why I was trying to get someone, anyone, to commit to bicarb. I'm not pretending to understand all of the issues clearly, but only enough to be afraid of causing any kind of significant shift to the left.. Most of the protocols that I've seen say something to the effect, "Consider Sodium Bicarb" yet I can't remember them ever explaining what I would consider exactly, or what my tipping points might be for those considerations. I know we're taught to look for ECG changes, but though I can imagine the changes, I can't remember them exactly as taught, and staying with the no research context of the thread would be really unfomfortable pushing bicarb without more clearly specific indicators.

These statements are the single most reliable marker for my very favorite discussions. The discussions where many already know the right answers and the reason for them are really not that interesting I think...Thanks for participating! I wouldn't know either, but I ran across an article that was saying that the lowered pH from the acidosis though not causing conduction issues, can possible cause contraction issues (Though it's unclear at the levels expected in this type of scenario, around 6.8). There are other electrolytes that are happy to screw with the conduction, though, theoretically, in this situation... It's a really difficult situation to study I guess...

What would happen to the pH of the pooled blood? Could a pH change have any effect on cardiac contractility?

You make an awesome point, one that I would have never have considered in a hundred years... I ran across this theory in my research, so I deserve no credit, and in fact have no idea if it's even valid...Why would you worry about the heart being overloaded? I mean, it's been beating with the same amount of veinous return this patient's whole life, right? Can you think of an issue here that would compromise the heart's ability to pump at the same rate, with the same force as it was before this issue occurred? Again, if I'd not read this, I would have never guessed it or been able to reason it out...it will be a possible contractile force issues, not a conduction issue. What do you think?

You know what DFIB, me too. This has stuck in my head and bothers me a lot. I've even kind of gone past being pissed at the cops to just being really sad that such a thing is possible. Maybe it strikes a cord as a father...him screaming for his dad to save him...and being the father of an autistic child, trying not to imagine these animals doing the same to my boy....whatever it is there is a different, emotionally bruising energy to this situation... So often it appears to me that the force used is punitive with the police continuing to scream "Stop resisting!" over and over to justify a bunch of pissed off, violent hehavior, when in fact most of the subjects movements seem not aggressive, but an attempt to defend themselves against the continued strikes. When I watch the cop near the end, sitting on the top of the pile, the victims's (Because he really is a victim at this point, no longer, if he ever was, a threat.) arms and legs pinned, hitting him over and over on his defenseless head and face with his Maglight I just want to blow his frigging head off...

Why the Ringers? No history of tampon use in this patient... :-) What would be s/s for deciding on the bicarb? What would be your tipping point that would cause you to push it? How would you deliver it? How much? What would be my criteria for monitoring "careful" in regards to kidney safety in this patient? How would I know if he'd had enough? Too much? What would you be worried about specifically? No problem on the ABG. You draw a sample, send it with your partner to the lab, you should have results within the next three or four days....You're welcome. :-) Grin, I'm behind the 8 ball too...I've seen your posts, and I'm confident that you are at least, and likely more so, able to contribute to this than I am. I learned these treatments, as many did, rote, with a satisfactory explanation for the treatments suggested, but have run across newer information stating that what I learned was wrong and counter productive..now just trying to start at the beginning and see what seems to be the most logical before exploring what other, science based institutions have declared. Will open it up to research as long as the peripheral issues are looked into and not the specific "Suspension" issues...know what I mean? Compartment syndrom, Rhabdomyolosis, pros and cons of using sodium bicarb in relation to those issues, etc are ok...

This is a imaginary patient, so I'm not sure. Let's call it static but zero impact issues associated with fall and/or restraints. Trying to limit this to circulation/electrolyte issues, and their associated symptoms/pathologies/treatments.