fiznat

BS. VF on the monitor means almost nothing? Absent respiration means almost nothing? An open femur fracture means almost nothing? I understand where are you are coming from, but there are some clinical signs that simply can't be ignored. A persistent heart rate of 250 cannot be ignored. A blood sugar of 1000 cannot be ignored. ALTERED MENTAL STATUS cannot be ignored!! From the law I posted: My contention is this: we as paramedics work under the purview of a physician, and perform interventions that may reasonably be construed as "directed by" that physician. That's what protocols are-- an extension of the physician's direction for our care. The law states that "consent...will be implied" to carrying out those orders "where an emergency exists." You state that I have failed to demonstrate that an "emergency" exists. Thankfully, this law goes as far as to define an emergency: That seems pretty clear to me. In "competent medical judgement," (notice: NOT specifically the judgement of a physician, but rather the much more general term "competent") the proposed treatment (in this case- transport to a hospital) must be "immediately or imminently necessary." Maybe this is where we differ. If I walk onto a scene and find a patient who is so altered that he or she is unable to have a coherent conversation, a patient who couldn't possibly understand what is going on - never mind comprehend the risks of a refusal - I feel that transport to a hospital is immediately and imminently necessary. Why? This is a patient who is exhibiting signs and symptoms of a myriad of potentially life threatening conditions, which I am absolutely unable to completely separate from much more benign causes. I DON'T KNOW if this patient is "just drunk," or having a huge head bleed. The presenting condition and the result of my assessment could just as easily point to either cause. There is absolutely no objective clinical basis from which you can determine that this patient is not experiencing a time-sensitive critical medical emergency. I don't care if you spend 10 minutes or 60 minutes at the patient's side. It just can't be done. ...So how can you honestly determine with any certainty that transport isn't "immediately or imminently necessary??" You talk a lot about patient advocacy. You are confronted with a patient who's clinical presentation suggests that he or she may possibly be experiencing a severe, life-threatening emergency. You have no way of ruling that emergency out, and the patient is incapable of a coherent conversation. What does the patient advocate do? Does the advocate err on the side of caution and get that condition ruled out, or does he hope for the best and accept an illegitimate and legally indefensible refusal so that he can head back to the station bunk room? You're right, load and go isn't the answer. How many minutes does it take to rule out a head bleed in this patient? Serious question. I disagree. And so do the states who have passed the laws I cited. Ruling out pathology is an absolutely critical step in managing any emergency. This isn't just some random, healthy looking dude we picked up out of a crowd. This is a patient with profound altered mental status, who is so incoherent that he can't even understand what you are saying to him. Disagree again. See above. Dude. It applies to procedures "recommended by" a physician in an emergency as defined by "competent medical judgement." Direct quotes. Are you really saying that the things you do in the field are not "recommended by" your medical control, and are not the result of "competent medical judgement??" Explain that one to me. Defensive medicine is equally in defense of patient's lives as it is provider's careers. I consider that to be advocating for the patient.

What?!? What's the difference Dwayne? Altered mental status is an emergency medical condition!! You think you can diagnose the problem in the field, and yet you call ME arrogant... Take a look a few posts down buddy- even the emergency room physician says he can't do that. How do you suppose you can? Another basic EMS concept for you: everything we do as paramedics is done under the licence of the medical control physician. That's why there are only "standing orders" and "direct orders." There's no such thing as "do what you want under your own license." Paramedics can't do that. Like it or not, we paramedics are nothing more than an extension of a physician license. Take away the physician, and you can't do a thing. The law is VERY relevant and absolutely does apply. I don't even understand what you are trying to say here. Are you are proving your point by saying that there are potentially sick people who we haven't met yet? So the whole concept of implied consent fails in your mind because someone, somewhere, must be drinking alcohol? So you KNOW what they're going to do at the hospital? How sure could you really be about this? Are you willing to gamble the patient's life on it? ...Or do you see it not a gamble at all, because your paramedic assessment and 10 minutes at the patient's side are plenty for you to make up your mind? Again, you call me arrogant. Disagree. Well I'm sorry you feel that way, but I really do think that it is obvious. This is a basic concept that I utilize if not on a daily, at least a weekly basis during my work as a paramedic. What's more, I feel that your solution is potentially dangerous, and will lead to poor outcomes for both you and your patients. Sorry if you feel my response to you was too strong, but honestly dude I just cannot see where you are coming from. My intent wasn't to be rude. I just don't get it. The posted citation doesn't apply at ALL? You honestly can't see any connection whatsoever and it didn't even deserve a reply??? I simply cannot believe that. Either you are being purposely obtuse or you're not reading the same document I am. And why would that be sad? This is a basic concept that both EMTs and medics need to understand. It has nothing to do with whether or not they took a 1,000 hour paramedic training course. Careful what you say-- some EMTs might take offense that you think they can't contribute to a discussion like this. At least if you can't listen to me, listen to the doctor:

It depends where you are. The requirements vary widely from state to state on who is allowed to ride on helicopters. Some states just require an EMT-P, while other states (like here in CT) require an RN or RT. Figure out where you want to work first, find out what kind of training they want, and then start developing a plan. **Also general advice-- make sure you get some time working with patients before you commit yourself to anything. EMS (even flight EMS) is oftentimes not what people think it is. You are VERY young yet. Your best bet honestly is probably to just go to college and get a bachelors degree- then after that if you still want to ride helicopters then fine tune from there out. Realize now that you will probably change your mind 10 times over the next 4 years, so concentrate on keeping doors open.

We do argue this all the time. I'm sure if you search a little more you can find a heap of multi-page, passionately argued threads on this topic. I know me and Dust have butted heads on it on more than one occasion lol. I am of the "you need EMT experience" camp. I think for you personally it might be worth considering moving forward with the EMT-P if it is getting paid for, but I do believe in general that experience as an EMT is essential to the development of an effective paramedic. My basic reasoning: -EMS isn't all about clinical medicine. Medicine accounts for maybe half (possibly even less) of what we actually do in practice. The rest is bedside manner, operations, managing a scene, adverse conditions, learning the system, giving reports to hospital personnel, working with a partner, interviewing family members and witnesses, lifting, etc, etc etc. Those are the things you learn how to do well as an EMT, and I strongly believe any good paramedic needs that foundation before he/she can expect to do medicine in the EMS environment. People like to blow this stuff off as "not important" or "easy to learn," but it really isn't. It can be very difficult to integrate all of those tasks smoothly together-- especially when scenes start to get chaotic. I would argue that those tasks account for probably more than half of what we do as EMS providers, require real skill and experience, and are as deserving of excellence as any other of our medical duties. -We need to respect the role of our EMTs. I work with an EMT partner every day and I need to fully understand his/her role in prehospital care. EMTs are FAR more important than has been let on in this thread, and I personally believe you can't fully understand that until you work the job. -Prospective paramedics need to know what they are getting into. EMS is not what outsiders think it is. The last thing we need is an influx of new paramedics who find out that this isn't what they bargained for. Pay your dues. Work as an EMT, and then go to medic school for the right reasons. -Etc.

Did you miss the state statutes I posted? I never once suggested the law needn't exist. I only stated that it is a difficult and arduous process to go through all of the statutes to find it. I finally broke down and did it, and all I get in response from you is personal attacks. You go on and on about how important it is to you to see the legal standard, and yet when I post it you somehow can't comment on it? What's up? I'm not going to take the bait with all the other stuff you posted in regards to me personally. I've managed to participate in this discussion without making personal attacks. How come you can't do the same?

Ah Dwayne. Its like you came on here and demanded we all prove to you that the sky is blue. You're in the minority here, the burden of proof should be on you! This seems so obvious to me that I can't believe I went this far, but see below for a bit of law from my home state of Connecticut. I cant figure out how to post a direct link, but if you want to verify it go HERE and search for chapter 319i. This is just an example, but there it is. Black and white state law. Now go prove to me the sky is blue. EDIT-- and before you complain that Connecticut is entirely inhabited by Nazis, here's one I found from Mississippi:

Quoted for truth. It doesn't matter how much they had to drink It doesn't matter whether the drug they took was legal or not It doesn't matter if they are in a house or in a field, on earth or on the moon It doesn't matter if they are male or female, black or white, big or small It doesn't matter who called the ambulance, or even if nobody called If the patient has altered mental status and is incapable of making an informed decision, that person is going to the hospital. This isn't cavalier, it has nothing to do with "Nazi Germany" The whole concept of informed consent is that if a patient is unable to speak on their own behalf, it is reasonable to assume that they would have wanted (and consented to) proper medical treatment. This is the way it works EVERYWHERE, because it protects both patients and providers in an otherwise sticky and difficult situation. Leaving confused/altered/semi responsive people at home on the floor with a half-scribbled refusal signature is NOT good patient care and absolutely will get you and your patient in trouble some day.

lol I swear you and I have this argument once a year. I don't really have all day to go through your points one by one so I just pulled this one out cause I think it is the main theme of your post. I fully respect your passionate argument for individual freedoms, but I really don't think this is the place for it. One of the first lessons we should all learn as baby EMTs is that ALL medicine is "cover your ass medicine." From the lowest rank all the way up to physician. Get used to it. CYA medicine is good for providers, and it is good for patients: think of it as institutionalized diligence. I can't tell you how many times I've done something because it was routine and it turned out to reveal something major that I might otherwise have missed. Covering your ass is covering your patient's ass, too. Make no mistake about it. If a patient is altered beyond the ability to understand the risks of an AMA refusal, the responsibility to make the right choice for that patient lands on YOU. You might as well sign the paperwork yourself. This isn't about "letting a person do what they want," it's about analyzing a situation where you - and only you - are making a potentially life or death decision for someone else. You need to respect that responsibility. It is not a rare occurrence that seemingly drunk people are actually experiencing a life threatening event. It is not a rare occurrence that alcohol intoxication alone leads to death and disability. If you decide to let an altered patient sign a refusal, know this: YOU (not the patient) are making the decision that is okay to take that risk. I don't deny that individuals have the right to make that decision for themselves, but this is a situation where you are choosing to take that risk against someone else's life. That's a big deal, and the standards need to be different. ...And before you tell me that this is not a life threatening condition, that he's "just drunk," take a moment and step back. It hurts to admit it, but YOU DON'T KNOW WHAT IS WRONG WITH THIS PATIENT. Admit it. You can't possibly. You may have a good idea, you may be 99.999% sure, but you don't know for sure. We're good at what we do, we know how to assess, we've seen it all before, I know, but have some humility. The stakes are too high to mess this up. As far as assessing the patient, I'm going to mostly leave that alone. The whole assessment process and the decisions that lead up to deciding whether a patient is "altered" or not is -- I think we can agree -- a complex and situation-specific task that we all have to make for our own patients. If this patient is deemed "alert and oriented" (IE not altered), then there is nothing to discuss: let him refuse. The argument (and this thread) comes from the point where we have decided this patient IS altered, and he still wants to refuse....

It isn't different in my book. The presenting problem wasn't "drunkenness," it was altered mental status. Patients with altered mental status are incapable of making an informed decision regarding their AMA refusal, and therefore cannot refuse. As far as identifying true altered mental status, well, we all know that can sometimes be tricky. Asking a patient basic information about who they are, where they are, what's going on, etc are generally part of the basic standard for assessing whether a patient is alert and oriented (by definition). If one of my patients fails that test, I won't let them refuse. Also for the record, a recent history of alcohol consumption does not necessarily indicate altered mental status. Not for my patients, at least. Altered mental status is a clinical condition that I assess independently of whatever happened before I got to the patient's side. It doesn't matter who called, and it wasn't a false alarm. True we don't know what the OP looked like that night and how well he was able to respond to questions etc, but it sounds like he was altered. Thats a legitimate EMS call that needs to be documented properly. Recipe for disaster. If the patient is "unable to legally give a refusal" on the basis of his altered mental status, that patient needs to go to the ED. Any other result is asking for trouble for all involved. This is basic EMS! On the basis of implied consent. This patient has a presenting medical problem and is not alert and oriented. That's exactly what implied consent is for. Yes. If you get so drunk that you are incapable of answering questions appropriately and in the opinion of EMS are not able to understand the potential risks of a refusal, then it is on you for getting that drunk. Off to the hospital you go. Altered mental status is a serious medical condition that has lots of causes-- many of them very serious. FOR THE OP: Just so there isn't any confusion, we're not suggesting anything wrong was done in your case. We don't know the details of what happened and what the EMS crew saw when they assessed you. If they let you sign a refusal, chances are you satisfied them that you were capable of refusing. We're just discussing general principles here as these can sometimes be tricky situations.

Thread is worthless without clarification from the OP.

Let me begin my reply by getting this out of the way: LOL. haha okay, Probably not. A lot of times police will respond to these kinds of scenes to assist the ambulance crew, but it doesn't sound like any laws were broken and I can't think of any reason why this would have any bearing on your probation. Doubtful. They probably just shook you until you woke up. We don't typically leave paperwork behind after a refusal. If you contact the ambulance service they should be able to supply you with a copy at your request. The complete paperwork will include the details of what the EMS crew found, what they did (their assessment/evaluation of you), what their advice was to you, and how you responded to that advice. It will also have your demographic information, times, and a detail of who was at your home that night. No. It is very unlikely that they gave you any medicines at all. They probably just assessed your level of responsiveness, checked your vital signs (possibly blood sugar), etc. There isn't much medical treatment for alcohol intoxication- generally the standard of care is to simply support the patient until they are able to clear the alcohol on their own. Like others have said-- check with the ambulance service to get the details of what really happened, and try to stay away from that grain alcohol! haha.

It also makes me cringe when people refer to patients as "customers."

I sat for a lecture about this from the guy running the program during the last JEMS conference. I don't remember every detail, but I remember him mentioning: -APPs do 100% followup on every refusal in their system. That means that APPs are calling these patients, and sometimes visiting, to make sure not only that they understood what the refusal meant, but also that they're doing OK and know how to get help if they need it. As I recall they also offer advice on how to streamline care (IE 911 isn't always the best option). -APPs have a slightly advanced scope of practice which I believe centers around cardiac arrest resuscitation. They respond to every code and do RSI, induced hypothermia, etc. They also serve as extra hands and I believe "run" the code to ensure optimum care. -Psychs. My impression was that they skip the ER and go to a facility or somehow streamline that process. All in all I remember thinking that it was an interesting take on EMS, but not something I would personally ever want to do. Although I do agree somewhat with the dogma that EMS must stick to "emergency" care, I think we would be mindful of the fact that it was partially through this kind of expansion of scope that got nurses to where they are today. I don't think anyone would disagree that EMS could very much benefit from a similar maturation...

^^ What the doc said. In an emergency we don't really care whether the GCS is 8 versus 6. Both are bad. In the ICU setting, though, small changes in mental status might mean much more. I imagine they have a real EEG for that, though.....

I'm not sure that there is much evidence out there that says paramedics are "bad" at intubating. Sure we probably miss more tubes than they do in the hospital on average, but then again we're not tubing prepped people in the OR either. Unrecognized esophageal intubations has been at ZERO percent where I work for several years thanks to continuous end-tidal CO2 monitoring. I really don't think this is a competency issue. It's been a little while since I looked at the research, but the evidence was more geared to whether ETI actually makes a clinical difference in the field-- which most research says it doesn't. There's no point in "getting the tube" if the patient won't benefit from it- high success rates or not. Wow, if that is correct that is super impressive. I kinda doubt it though. Can I see this evidence and research you referred to? Not that I think you're lying, but a lot of people make the mistake that the other poster (above) did and forget about which populations are being studied. 30% survival to discharge is unheard of around here.

This is a bit misleading. The "survival rate" in Wake County is not 40%. That (37% actually) is the rate of ROSC in a very specific population of patients (non traumatic arrest, VF or VT, over the age of 16, etc etc etc). The percentage of all patients who make it to discharge from the hospital is more like 11%, and if you insist that they are neurologically intact (not broccoli), you're looking at a dismal 7.8%. True "code saves" are a real rarity across the U.S., even in Wake County. Also, the improvement in survival rates that was observed in Wake County was with the combined changes of the 2005 ECC guidelines (no more stacked shocks, focus on CPR, etc) and the addition of induced hypothermia. I think the argument could be made that most any system who made these combined changes would have seen a similar increase in ROSC if they had studied it like WC did. http://wakeems.com/saem/ As far as the OP's point, I agree that we need to learn to do our own jobs better. Don't forget though, that there are some limitations to our care that aren't exactly "our fault." Intubation competency is directly related to experience (which is limited in the field), and cardiac arrest survival rate is very much limited by the science and state of medicine. It's not like every code gets saved in the hospital, either.

I guess you can't knock a positive message, but jeezz... only in the FDNY.

I said I see more of the former than the latter... I see more unhappy people than happy ones. I agree with your point anyways, though.

I'm really amused with all this aussie lingo. Best part of the whole thread as far as I'm concerned...

OP- There are lots of opinions regarding EMS, and Dust's are just one of those. You should know though that a lot of people get into EMS thinking that it is something different from what it is. Many, many people end up disillusioned and unhappy- stuck in a job that they can no longer get themselves out of. That said, there are a LOT of people who are really happy with what they do, and get satisfaction out of it every day. My personal experience is that there are more of the former than the latter, but that's just what I've seen. I'm really not convinced that the ratio of unhappy to happy people in EMS is any different from any other profession. You should listen to the opinions of the more seasoned folks here, and just remember to keep your eyes open as you get into this work. That said, enjoy your class!

Damn Dust, you've gotten more even more bitter than I last remember. There are some good aspects to this job that are probably worth mentioning, no?

If you've been in EMS for 8 years you should know the answer: don't speak up. Not yet, anyways. Earn your stripes for a little while before you start suggesting the company change the way it manages it's employees. You'll have plenty of time in the future, and your efforts will be much more effective with a little time under your belt.

Eh, different strokes. I very much enjoy the fact that I can do what I choose with my time when I'm not on a call. I wouldn't want to work for someone who had the attitude of "everyone needs to be busy on a task 100% of the time they're on shift." When the tones go off for a call, I am ready to go every single time. I don't generally drive so that's not an issue, and my boots zip up real quick. I see no reason to do anything different from what we currently do. In any case- what do you do at 0300 in the morning when there are no calls? Clean the underside of the ambulance?

About the exact same setup as me. We work 12 hr shifts here for the most part, but the bunk room arrangement is the same. I love getting my early morning nap! lol

I'm with your wife, Dwayne! I much prefer simple shirts rather than the joke stuff. EMT city logo on the back, nothing (or little) on the front would be ideal. Keep it clean, simple, and neat!