Hospital settles for childs death, faults EMTParamedic

[Doczilla]

Rid-

I think you're talking about 2 different things here. Triage is not necessarily considered a "medical screening exam" to satisfy the EMTALA requirements. Per EMTALA, the MSE and stabilization is all that is REQUIRED of the hospital for any patient who comes through the door, and this has generally been held that it must be performed by a physician or representative (PA, NP, APN). After this screening exam, if it is found that no further stabilization is necessary, the patient can legally be discharged from the ER. While it is true that paramedics are not generally considered trained or qualified to do this MSE, triage is not an MSE, since the patient is not being sent home from there. Rule 482.55 sets forth the requirements of what personnel may perform the MSE, though it is vague and subject to interpretation. The upshot is that the hospital bylaws determine who meets this criteria. The CMS position on this is that it does not need to be a physician who performs the MSE, but may be a non-physician member of the hospital staff. They specifically cited an ER nurse as an example of a non-physician staff member that can perform an MSE. RNs are frequently used to perform MSEs in Labor & Delivery. Most hospitals interpret this to mean MDs, DOs, PAs, NPs, or APNs. Again, triage doesn't necessarily qualify as an MSE. If the person at triage looks you over and says, "you don't need anything more in the ER, go see your doctor", then it is an MSE, and that person who said it has to be identified in the hospital by-laws. State law may determine who does triage, but EMTALA does not.

The next few comments are not directed at you, Rid.

Both of you have irritated the living crap out of me with this drivel.

Spenac: You have absolutely no idea what the patient's presentation was on the first visit. Initial symptoms of meningitis are vague and nonspecific: fever, headache, and vomiting are extremely common presenting complaints in pediatrics. We cannot nor should not perform lumbar puncture (the only way to truly diagnose meningitis) on every one of these patients. To say that the physician committed an error the first time by sending the kid home based on hindsight 48 hours later is making assumptions based on information that you don't have. You don't know if the patient had altered mental status, meningeal signs, or any other worrisome signs at the time. I usually find your posts intelligent and well thought out, which is why I'm hoping that someone else got hold of your login information.

Ventmedic: 2 days of fever and headache does not make a patient triage level 1 or 2. "Bounceback" doesn't either. There would have to be something in the patient's presentation that indicates significant illness, such as altered mental status, abnormal vital signs, etc. I fail to see how you think that "traditional ER nursing" questions are outside the scope of the paramedic or how they would detect the underlying severe illness. See also my comment above to Spenac regarding assumptions you are making about the child's presentation to the ER.

Death from meningitis while still in the ER means that the patient was doomed. There is nothing that can be done to save the patient at that point, nor probably for several hours before that. The fact that the patient was seen by a physician 2 days before her death does not mean that there was an indication of the potential for severe underlying illness at the time. Both of you are buying into the media hype that emergency providers, whether paramedics, nurses, or physicians, have a magical crystal ball to detect disastrous illness that presents like the swarm of nonserious illness that we see every day.

This is exactly like the comments we hear on the news from ill-educated public about the care provided by EMS to patients when they have no idea what went on during a call. And both of you know better.

'zilla

[spenac]

Both of you have irritated the living crap out of me with this drivel.

Spenac: You have absolutely no idea what the patient's presentation was on the first visit. Initial symptoms of meningitis are vague and nonspecific: fever, headache, and vomiting are extremely common presenting complaints in pediatrics. We cannot nor should not perform lumbar puncture (the only way to truly diagnose meningitis) on every one of these patients. To say that the physician committed an error the first time by sending the kid home based on hindsight 48 hours later is making assumptions based on information that you don't have. You don't know if the patient had altered mental status, meningeal signs, or any other worrisome signs at the time. I usually find your posts intelligent and well thought out, which is why I'm hoping that someone else got hold of your login information.

This is exactly like the comments we hear on the news from ill-educated public about the care provided by EMS to patients when they have no idea what went on during a call. And both of you know better.

'zilla

Sorry Doc. No it was not my evil twin. It was me in a minute of stupidity. Your absolutely right the s/s may not have been present to warrant a suspicion of anything serious 2 days earlier. I have had calls from the hospital a day or two after taking a patient that what all felt was nothing that needed an ambulance or ER turned out to be life threatening. Having reread my statements yes I feel like a freakin moron. Wow I am sorry I did blow that call big time and on something I have seen in the field. In the famous word of Homer Simpson "Doh". Thank you for correcting me and hopefully helping others less experienced from believing my misstatement.

I did get the part right that she was to far gone by the time her parents got her to the ER though it would seem, based on your comments. So can I at least get a 50 on this assignment rather than a 0.

[VentMedic]

2 days of fever and headache does not make a patient triage level 1 or 2. "Bounceback" doesn't either. There would have to be something in the patient's presentation that indicates significant illness, such as altered mental status, abnormal vital signs, etc. I fail to see how you think that "traditional ER nursing" questions are outside the scope of the paramedic or how they would detect the underlying severe illness. See also my comment above to Spenac regarding assumptions you are making about the child's presentation to the ER.

Both of you are buying into the media hype that emergency providers, whether paramedics, nurses, or physicians, have a magical crystal ball to detect disastrous illness that presents like the swarm of nonserious illness that we see every day.

This is exactly like the comments we hear on the news from ill-educated public about the care provided by EMS to patients when they have no idea what went on during a call.

We are talking about triage within an ED. We are not talking pre-hospital. If you want to go there, there are also enough examples in that area that has demonstrated a need for an improvement in education also.

Scope of practice? How about training and education? We could get into a long list of things that a nurse is much more familiar with for day to day health and chronic care than a Paramedic. Where to start? G-tubes? Insulin? Nutrition? Dialysis? Ostomies? Chronic illness? BMs? I&Os? Indwelling cath care? Decubitius ulcers? LVADs? Trach stoma? Post operative wound healing care and complications? I haven't even scratched the surface of med-surg problems seen in an ED on any given day. How about all the things that usually have little interest to the Paramedic working in the field. I know you've read some of those threads. The Paramedic is trained for prehospital medicine and not on the broader sprectrum of med-surg problems. Pick up any Paramedic text and then pick up the many textbooks, including the Lippincott, to do a little comparison. How much information are you going to find about Lupus, renal failure, quadri or paraplegic issues and identifying wound care situations are you going to find in the Paramedic text? Nurses will have a base education and work experience with these patients. Granted not all will be an immediate emergency but some may need to be attended to rather quickly just the same.

A nurse and a Paramedic are very different in education. A nurse who is working triage in an ED has not only received a 2 year degree in basic nursing but has also done additional education, training and working in various areas of the hospital and ED to get that triage seat. A Paramedic education may take as little as 500 hours in some states to obtain without any college education and very limited exposure inside the hosptial. Heck, even some of our PCTs have over 700 hours of education/training. Many get this cert while they are continuing to nursing school. I actually find it insulting to the LVN who for many years worked in all areas of the hospital and had at least one year of education to be replaced by a Paramedic with no inhospital patient care experience and limited knowledge of "med-surg" procedures which make up more than 90% of emergency room patients. And yes, LVNs were trained for emergency situations. If the Paramedic wants to be like a nurse and work in the same capacity as a nurse, education is the key. For an ED to step down its standards in one area while the rest of the healthcare world within the hospital is advancing does not make sense.

Maybe if the paramedic certification/licensure had grown up to at least have the same minimal education requirements as other healthcare professionals, this would not even be a topic for a thread.

Doczilla

The fact that the patient was seen by a physician 2 days before her death does not mean that there was an indication of the potential for severe underlying illness at the time.

News article

After talking with the child's doctor and seeing that Victoria wasn't getting any better, they brought her to the emergency room two days later.

It does bring about more questions that should be addressed if this fact is known. Kids don't usually doc hop for no reason especially if they have a pediatrician who most parents would rather trust.

The one thing about meningitis in a child, it won't be long before you know you missed the diagnosis.

Fortunately, some hospitals do take the health of children seriously and don't just blow off any and all sniffles that comes along nor is a lumbar puncture necessary either. However, a child deserves the benefit of the doubt regardless of your opinion of the parent(s) or how much BS you perceive it to be to take up your time. No need to have a crystal ball if you and your hospital practice good medicine. Mistakes will still be made but less serious ones if certain guidelines and quality care are maintained to the highest standards possible.

My statements come from work experience and not reading media hype.

[reaper]

I agree on the need for better education and degree programs for medics. The one thing I hate seeing over and over is people saying "degreed nurses". Up to about 4-5 years ago, not all nursing programs in this country were degree programs. Alot of RN programs were still 2 year certificate programs.

Yes, it is nice to see that nursing has steered it's way to degree RN's. But, unless you are talking about new RN's, not all have degrees. I have seen a lot of online RN's in hospitals.

So yes, we do need to push paramedic education to higher standards, but lets stop holding RN's up as the holy grail of which we need to be judged by.

Sorry for the rant, back to the subject now.

[VentMedic]

I agree on the need for better education and degree programs for medics. The one thing I hate seeing over and over is people saying "degreed nurses". Up to about 4-5 years ago, not all nursing programs in this country were degree programs. Alot of RN programs were still 2 year certificate programs.

Yes, it is nice to see that nursing has steered it's way to degree RN's. But, unless you are talking about new RN's, not all have degrees. I have seen a lot of online RN's in hospitals.

So yes, we do need to push paramedic education to higher standards, but lets stop holding RN's up as the holy grail of which we need to be judged by.

Sorry for the rant, back to the subject now.

If you want to do the job of another profession, you should have at least the minimum educational level of that profession....not less than 1/2.

RNs started changing to the two year degree in the 1970s. That was the same time colleges started with their degree programs for Paramedics. For awhile it was thought that the Paramedic would emerge as the stronger and very respected profession with a lot of promise for an outstanding career choice. At least that is what the college career counselor said when I signed up for the program in 1978.

The thing to remember about the nursing profession is that they know a two year degree is just the beginning of their education and training. They may work on a med-surg floor for several months or several years while mastering the skills for that area. They may also take the prep work such as training courses for other specialties which can be 1 - 2 semesters in length for each specialty. This also includes the specialties for Critical Care, Flight and Prehospital. ACLS, PALS and NRP may be part of the extra certs needed besides the professional certifications. After they get accepted to a Critical Care Unit, another several months of training and education will be in store for them. If they choose a specialty such as CVICU, NICU or PICU, many, many months of training may be needed before they are truly "solo". If they want to do transport for any specialty team, they may need 3 years with 5 preferred to even apply. If accepted, it may take up to a year to get all the additional education and training, including numerous intubations, to be ready for transport. After that, their competencies are closely watched with many hours of more mandatory training and education.

Guess what group makes up many of the applicants for online nursing programs such as Excelsior? Unfortunately no matter how much your ego leads you to believe you know, there should be no shortcuts for the hands-on skills and the hours of numerous patient contacts that a nursing student will have during clinicals. That could be the reason the nursing graduate from Excelsior is not accepted in all states. Often it is the thought of doing these clinicals that make some seek out programs such as Excelsior. They may also believe it is the easier and less time consuming than going through a regular program. However, most lack the discipline to finish.

The diploma programs that are still around may or may not give the student the status of RN. Most are not associated with colleges to earn a degree. Until that degree is earned, some states may only recognize the training as a PCT or LVN.

[reaper]

Vent,

I agree with you on the education of Rn's and Paramedics. While medics may be stuck with courses that do not have a lot of education hours, it is the dedicated medics that go on from there.

The ones that continue their education through courses( ACLS,PALS,ITLS,Critical Care) just like the Rn's do.

It would be nice it medics could get the 3-4 years experience, before going solo. Unfortunately, It is not set up for it at this time. Maybe if we push for the higher standards in EMS, it can get to this point.

What I was saying before, is we are two different professions and you can not always compare medics to Rn's.

I have known great medics who are dedicated and know their stuff. I have known medics that I would like to run out of EMS, before they kill someone. I have known Rn's that are top notch and would trust with my life. I have also known Rn's that knew less then my 8 yo kid and you wonder how they became an Rn in the first place.

My Ex is a Rn and she said it best one time.

Rn's are taught a little about a lot and then specialize in something. Paramedics are taught a lot about a little. We focus on Emergency medicine and not the big picture!

[Doczilla]

We are talking about triage within an ED. We are not talking pre-hospital. If you want to go there' date=' there are also enough examples in that area that has demonstrated a need for an improvement in education also. [/quote']

You are correct that we are talking about triage in an ED. I fail to see how insisting on someone with more education leads to better triage.

Again, this fact alone does not make a higher triage category. What questions do you think need to be addressed?

We're not talking about blowing off a patient or their parents or thinking that the complaint is BS. We're talking about clinical manifestations of worrisome disease that is evident on the limited exam and history done in triage, or the complete exam done by the physician on the patient's previous visit. To suggest that an RN would have performed better triage in this case than the paramedic needs to be supported by some evidence. So far, all you've managed to say is that nurses are smarter, in a way that is condescending to paramedics.

Workups must be tailored to the severity of the presenting signs and symptoms. We cannot perform a million dollar time-intensive radiation-intensive workup on every child with fever, because we would cause more spinal infections and cause more cancers than we found. And if you don't think that we need a crystal ball, then you don't understand that disastrous diseases frequently come to the ER with very subtle symptoms. "If I and my hospital practice good medicine", this will only catch some of these cases.

'zilla

[VentMedic]

I don't know why you think the rest of the hospital isn't doing something similar. Specialized techs are cropping up in every area. EKG techs, IV techs, lab techs, phlebotomists, radiology techs, transporters, physical therapists, occupational therapists, scrub techs, and ortho techs. All of these are doing jobs once done by nurses. Why should the ER be any different? And with current rates of overtriage and undertriage by nurses, who's to say that someone else can't do it better?

Me condescending? You just insulted most of the "techs" in a hospital. You must not be aware of how much these professions have progressed or you think of them as insignificants that got the RNs' leftovers and have not taken the time to know what their education level is. I guess it is easy to see how much you think of the "techs" in the hospital in your hierachy of patient care.

I have not seen an IV tech around for about 20 years so I can not comment on that. RNs do most of the IVs as well as the PICCS.

EKG techs may also be Cardiopulmonary, Respiratory Therapist or CV Technologists, all of which require at least a two year degee. Just because you see someone doing a simple skill does not mean they are uneducated. Departments have had to cut out the majority of their unlicensed staff many years ago and the licensed staff must now do those "tech" skills. Hence, RNs are again doing their own EKGs and IVs.

Lab Tech start with a 2 year degree but a Bachelors is now their preferred minimum. In some hospitals, it is a CNA who has extra training, MLT (2 or 4 year degree) or a phlebotomist which is low level with 150 hour cert.

Radiology: minimum of a 2 year degree with Bachelors preferred for specialty

Respiratory: minimum of a 2 year degree with Bachelors preferred

Occupational Therapist: Bachelors minimum with Masters preferred

Speech Therapist: Bachelors minimum with Masters preferred

Physical Therapists: Masters minimum and Doctorate preferred

Do you even have any idea of what each of these professions do or are capable of doing and what role they play in patient care?

You just finished your residency so you may not be old enough to know how much technology has evolved of the past few years and the growing need for specialists. Yes, I, too was an OJT "tech" almost 30 years ago but it didn't take long to see that education was necessary. So, why should the ED again settle for a "tech"? Until the paramedic can at least get the same education level as the rest of the licensed staff, they are techs. A two year degree should not be that much to ask for. Most ED jobs don't even require they have prior experience to be an ED tech.

Like paramedics, they have to spend time in special classes or at the bedside with experienced providers learning these things, and it comes after their initial training. You seem to think that nurses have cornered the market on continuing medical education. Paramedics go to CE classes too.

I was not referring to "CME" classes for RNs but the college programs to prepare RNs for different specialties that last 1 - 2 semesters. There are also the hospital sponsored programs that run for several week and months to get the RNs ready for their chosen specialty.

Some new Paramedics are lucky to get 3 shifts with their training officer or "senior" partner that might have just a few more months than they have of experience. The whole EMS world is not as rosey as you believe it to be. That is why some of us old dogs are still in the race hoping for some improvement through legislation.

So far, all you've managed to say is that nurses are smarter, in a way that is condescending to paramedics.

I would say that an RN who works triage has a higher educational level in medicine with a broad spectrum of medical problems as well as EXPERIENCE inside the hospital working with medical patients. Would you want a 3 month medic mill wonder triaging your child? While there are excellent Paramedics out there who have excelled there are many that haven't. Have you not noticed the comments on education on this forum?

And with current rates of overtriage and undertriage by nurses, who's to say that someone else can't do it better?

Remember doc, you are going to be working inside a hospital. Don't disrespect the lowly "techs" (what a crappy attitude you have toward Radiology professionals) and all those nurses you believe to be so incompetent. These nurses also have to manage critically ill patients for several hours until an ICU bed is ready. I am truly disappointed that you feel this way about the people you work with inside the hospital. The Paramedics will get their due respect when they eliminate their weakest links in their educational system that keeps the playing field uneven for them. I've held out for 30 years waiting for it and have only seen it more erroded by more "skill" certs instead of education. As long as there is not an incentive for the Paramedics to get a higher education level and they are led to believe their 700 hours is just as good or better inside the hospital than the many "techs" and RNs who have much more education and training inside the hospital, there will still be a need for 3 month medic mills to now meet the demands of the EDs.

I fail to see how insisting on someone with more education leads to better triage.

Quess you wasted a lot of time and money on medical school.

[chbare]

I did not see his post as condescending. I think his definition of a tech differs from your definition. I see his point and see this occurring in my geographic location as well. One example is in the cath lab. I see hospitals taking people and putting them through an in house program where upon completion, they work as a cardiovascular tech. I think there is a difference between say a lab technologist and a lab technician. In my area, one has several years of education where the other has several hours.

Take care,

chbare.

[VentMedic]

I did not see his post as condescending. I think his definition of a tech differs from your definition. I see his point and see this occurring in my geographic location as well. One example is in the cath lab. I see hospitals taking people and putting them through an in house program where upon completion, they work as a cardiovascular tech. I think there is a difference between say a lab technologist and a lab technician. In my area, one has several years of education where the other has several hours.

Take care,

chbare.

This is more about the education rather than the word itself. He thinks that those professions are just spinoffs of nursing. Physical Therapy and Rehab medicine got its routes long before RNs were getting their acts together. As technology evolve the RN with a diploma or 2 year degree could not keep up with all the changes and still do their nursing profession. RNs used to work the ambulances also and pick up sick people. RNs, however, are now feeling the fact that they are in the category of the 2 year degree being the minimum degree for licensure while the other professions have moved or are moving on to Bachelors.

Those "techs" that were mentioned have NATiONAL standards. In his statement for Radiology professionals implied that they don't need an education to do what they do.

Have you actually asked what the titles are for those lab technicians which yes, the Technologist can go to Masters and Doctorate just like most of the other healthcare professions. But, the question is what is the minimum for them to be LICENSED? Certified or unlicensed staff have a totally different set of responsibilties. I doubt if you would confuse a CERTIFIED Nursing Assistant with a LICENSED nurse.

BTW, have you looked at the educational level of the "cath techs"? The requirement that is being established in this area is a 2 year (Associates degree) which is usually Respiratory, Cardioppulmonary or Cardiovascular science and with a licensure to accompany one of those degrees. I worked as a "Cath Lab Tech" but functioned under my RRT license. Again, these are National standards and not just whoever wants to make some rules in that county. This is stemming again from various legislative and reimbursement issues as to getting what you pay for. It may just take some areas longer to comply than others. Some of these cath techs may have been grandfathered in for some licensure with special provisions or they are back in school completing the needed education.

The surgical tech is about the only one that can still be OJT and that, too, will be changing if their duties are more than with just equipment. In RT, we don't require our equipment techs to be licensed. They are usually students who move on with licensure. But again, there's a vast difference in responsibilty between a licensed, certified and OJT "tech" these days and it is the education that establishes the standards for the differences.