Is Having More Ambulances The Solution?

[JaxSage]

Obviously, this isn't an issue that everybody is going to agree with. That is completely fine. I'll agree that ultimately it's safer to transport everybody than to deny one person...as far as covering your behind goes.

As far as somebody complaining of chest discomfort that presents as heart burn...you'll just have to use your own common sense and street smarts, which is what most of this job consist of. I don't know why the medics didn't transport that guy, because he would have been someone I would have transported. As I said before, people have misused their ability to deny people transport, I won't keep that a secret. However, when it comes to this job, it's about using your common sense. If you're going to second-guess every ridiculous problem and make the most nonsensical complaint into a Dr. House project, then let's not complain anymore whenever people call for the most off-the-wall problems. Because afterall, you just never know.

If you don't feel confident in your skills, education, and judgment to deny someone transport, then don't deny anyone. Plain and simple. Not everybody should be trusted with this authority and not everybody who has been trusted with it should use it. Honestly, I think it's ashame that EMS personnel are judged to be too stupid to be trusted with this ability. I think we have some of the greatest medics in my agency who are sharp, knowledgeable, and on-point. If you can't say the same about your agency, then that's a problem. Denying transport is not a norm and many agencies would feel uncomfortable implementing it. Ultimately, it comes down to the best interest of the city/county to better serve them, and in my opinion, better serving the citizens should not involve playing cab driver.

[WolfmanHarris]

As far as somebody complaining of chest discomfort that presents as heart burn...you'll just have to use your own common sense and street smarts, which is what most of this job consist of.

Forgive as I'm grass green new, but that's not what I believe this job is about at all. We're not cops looking at someone trying to figure out if they're lying or not so in most medical cases I don't see where street smarts comes into it as far as treatment goes. There are times for it sure, but not in field diagnosis. As for common sense? What assessment relies on that. Should we not be basing our practice on sound clinical judgement? And from that should the "smarts" we develop not be about familiarity with medicine that allows us to come quicker and more confidently to our clinical judgment? Maybe I'm missing something you're trying to say.

[crotchitymedic1986]

Here's another one for you, from my ER days (and I have several similar stories) . 42 year old male was lifting weights, began to experience severe right wrist pain. The health club calls 911, patient has no other symptoms. paramedics tell patient he might need to get it x-rayed. pt drives himself to hospital, drops dead from MI in triage, but luckily was resucitated.

Similar stories happen every week somewhere in the US.

[CBEMT]

Here's another one for you, from my ER days (and I have several similar stories) . 42 year old male was lifting weights, began to experience severe right wrist pain. The health club calls 911, patient has no other symptoms. paramedics tell patient he might need to get it x-rayed. pt drives himself to hospital, drops dead from MI in triage, but luckily was resucitated.

Similar stories happen every week somewhere in the US.

Let me guess. If YOU'D be onscene, you would have caught the obvious wrist pain MI with a 12-lead, because you do that for all possible orthopedic injuries. :roll:

[JaxSage]

Forgive as I'm grass green new, but that's not what I believe this job is about at all. We're not cops looking at someone trying to figure out if they're lying or not so in most medical cases I don't see where street smarts comes into it as far as treatment goes. There are times for it sure, but not in field diagnosis. As for common sense? What assessment relies on that. Should we not be basing our practice on sound clinical judgement? And from that should the "smarts" we develop not be about familiarity with medicine that allows us to come quicker and more confidently to our clinical judgment? Maybe I'm missing something you're trying to say.

Let me give you an example, Harris. One time, my parnter and I were called for an animal bite at one of the high schools. This 15-year-old kid said that he was attacked by a dog. The only signs of a dog attack were a small abrasion on his face and on his hands. Nothing else. He strongly claimed that he was attacked by a dog. Even his sister said that he would never make up a lie like that. We doubted he was attacked by a dog, but he stuck with his story...until later when an officer and the principal talked with him. He finally admitted that he was jumped. We know that when dogs attack, they bite and scratch. He had no scratches, no bites, nothing that would suggest a dog attack.

Another time, a partner and I went to the jailhouse for a seizure. One of the inmates were lying out on a bed all twisted up and everything and we were almost convinced...but we still had our doubts. So, I put an ammonia inhalant to him and he started shaking then he would stop. I popped another one to him and he started shaking again. I did it a third time...you get the picture. On top of that, we were told that he has faked these seizures before. You be the judge.

If you don't have common sense on the job, then there is no way you could function well in this field, no matter how book-smart you are. Yes, we do use our clinical skills to evaluate the patient...but even that has to be supplemented with common sense. It doesn't take much to rule out who's full of crap and who isn't.

[WolfmanHarris]

Okay thanks for explaining. I don't agree.

I will admit that knowing that a injured child was jumped rather than bit may increase my index of suspicion about other injuries, but not by much if I'm already thinking the patient is a poor historian. The same with knowing that a pt. has a history of faking seizures (though I'm yet to see a convincing fake). However, I honestly think you're confusing common sense with clinical judgement. Knowing that a patient's presentation does not fit and exploring alternative causes is clinical judgement based on medical knowledge.

Common sense on the other hand refers usually to an understanding of something that is generally innate in a group. The reason why we also bemoan the loss of common sense is that we sometimes forget that our shared experiences are growing further and further apart. For example, when more people within our population were employed in industry and agriculture they had a greater familarity with machines and the maintenance. From this familarity they would be more comfortable repairing their own house as they are used to working with their hands. However as people have more diverse jobs than we once did and less exposure to these concepts, it is no longer common sense to know how to wire a light switch or troubleshoot a small engine.

The common sense you're referring to could only come from the shared experiences of others within EMS and once again what you're referring to sounds more like knowledge than sense to me. Common sense in my understanding would be more about the techniques we pick up for prepping tape for an IV start, or keeping that k-basin handy after giving the glucagon. These things may or may not be taught in school but along the way we pick up these shared experiences and establish a common sense.

To rule out who's full of crap you need a thorough understanding of the medicine to accurately judge someone's condition. I think you're not giving your education enough credit as you don't realize how much you rely on it in these judgments. Experience is incredibly important; I'm not doubting that at all, but I don't think you get from experience what you seem to be arguing for. I think experience builds relevance, provides real world exposure to what was previously theory and places things is context. I don't believe it does (or should anyways) be providing critical theory. If it is than the classroom part of the education has failed to lay down the fundamentals.

[VentMedic]

Let me give you an example, Harris. One time, my parnter and I were called for an animal bite at one of the high schools. This 15-year-old kid said that he was attacked by a dog. The only signs of a dog attack were a small abrasion on his face and on his hands. Nothing else. He strongly claimed that he was attacked by a dog. Even his sister said that he would never make up a lie like that. We doubted he was attacked by a dog, but he stuck with his story...until later when an officer and the principal talked with him. He finally admitted that he was jumped. We know that when dogs attack, they bite and scratch. He had no scratches, no bites, nothing that would suggest a dog attack.

How long did you take your truck out of service to win this peeing match with a child?

Another time, a partner and I went to the jailhouse for a seizure. One of the inmates were lying out on a bed all twisted up and everything and we were almost convinced...but we still had our doubts. So, I put an ammonia inhalant to him and he started shaking then he would stop. I popped another one to him and he started shaking again. I did it a third time...you get the picture. On top of that, we were told that he has faked these seizures before. You be the judge.

3 ammonia inhalants? You were determined to make a point. What if the guy had a TBI or CVA?

Toss in a couple other factors concerning the patient and that inmate could have made you his bitch or at least had some satisfaction in court.

If you had done a little more book learnin' you would have studied the consequences of ammonia inhalants. You might also have learned a little case law about using them in environments involving prisoners and incarceration.

Florida had a case where a prison nurse based her assessment on a patient's response to an ammonia inhalant. Guess what? The nurse and the State of Florida lost. Several other states have also re-examined their "ways" of lie detection.

If you don't have common sense on the job, then there is no way you could function well in this field, no matter how book-smart you are. Yes, we do use our clinical skills to evaluate the patient...but even that has to be supplemented with common sense. It doesn't take much to rule out who's full of crap and who isn't.

Both of your examples did not demonstrate common sense as much as they did a need to prove you are right regardless of other consequences.

You had to take your truck out of service until you make your point against a 15 y/o child. Don't you think the truth would have come out anyway without your heroics and wasting time? You probably could have transported 3 more patients if you had not be so intent on proving your "skills". You may also have foiled a child's cry for help for other reasons but you were to blinded by a few scrapes to see a bigger picture.

In your jail example, you did not indicate any medical assessment. You again was just intent on proving a point totally based on the fact the patient was a prisoner. Believe it or not, some hospitals have entire wings devoted to prisoners. Some are sick enough to be awaiting organ transplants.

Add this to all of your preconceived assumptions about cancer patients and women with abdominal pain, your judgements for medical care have little to do with medical assessment.

So far, you have demonstrated excellent examples where there is truly a need for an improvement in Paramedic education. It is pretty amazing that you would even choose these examples to prove your point.

Here's a couple of articles about ammonia inhalants.

Bledsoe BE. This procedure stinks: the hazards of ammonia inhalant use.

Journal of Emergency Medical Services (JEMS). 2003; 28(3):52-53

Ammonia Inhalants: Not to be taken lightly

By Howard Rodenberg, MD, MPH, Dip(FM)

http://info.jems.com/jems/exclus04/e0504i.html

[JaxSage]

How long did you take your truck out of service to win this peeing match with a child?

Actually, since he was a minor, we would have transported him anyway. However, since it wasn't an emergency, we decided to call his mother and asked what she wanted us to do. She wanted us to wait until she got there. We don't just throw children on the back of our ambulance in non-emergent situations without first contacting a parent or guardian.

3 ammonia inhalants? You were determined to make a point. What if the guy had a TBI or CVA?

It's a good thing that he didn't. Whew!

You may also have foiled a child's cry for help for other reasons but you were to blinded by a few scrapes to see a bigger picture.

A child's cry for help? If it meant catching those who jumped him, then that's a police and a school administration concern, both of which were there. They would be better able to meet his need than we in EMS would have.

In your jail example, you did not indicate any medical assessment. You again was just intent on proving a point totally based on the fact the patient was a prisoner.

In fact, we did do a medical assessment, believe it or not. What we did had nothing to do with whether or not he was a prisoner. I have transported a prisoner before because he was definitely in medical distress and he was given morphine to help his pain. Regardless of how we feel about prisoners or anybody's status in society, we still do our job.

So far, you have demonstrated excellent examples where there is truly a need for an improvement in Paramedic education.

No, I have shown examples that I hadn't explained thoroughly enough.

Obviously, this is just not an issue that everybody would agree with. I'm absolutely fine with that. I thought that you guys would have been thrilled with the possibility of not having to transport everybody. But I was wrong. No one feels comfortable with it and it seems that almost everybody who responded seem to justify transporting everybody. There are both pros and cons to it.

Believe it or not, we actually do a thorough assessment before denying anybody, but according to many of you, no one could do a thorough enough assessment to deny anybody, even if a patient called because he bit his tongue eating fried chicken. Who knows, maybe that tongue would get infected and fall off...and ultimately the patient would have a huge MI and fall over dead. Then the family would sue us because we didn't take the patient to the hospital for biting his tongue eating KFC...and the family would win millions of dollars...something that we don't have in this agency. So instead, the family would go to the news, then would go to Washington, they would have a petition signed by thousands of people who would seek to shut this place down...and everybody would lose their certifications, retirement, and no other EMS agency would want to hire us, and we'll be blacklisted, and our homes would be taken away, and we'll turn to drinking and drugs, get arrested and sentenced, and we'll be faking seizures just to get out of jail...but that won't happen because you have nuts shoving up inhalants in our noses just to prove that we're faking.

I have a lot of respect for EMS to be treated like a cab service. Soon enough, we'll be extending our services to deliver people's groceries, servicing their cars, washing their clothes, mowing their lawns, and taking their dogs for a walk. Our motto should be, "You call, we haul...and everything else in between." And the way the economy is, we might as well extend our services so that we could raise funds to keep us in business, because knowing the respect we get, the government is going to cut off funding for us if push came to shove. So let me set up the EMS lemonade stand.

So if this insults anybody, I'm sorry. But EMS is more than babying everybody who calls for the stupidest things. But that's just my opinion. And I'll end it at that. This is my last post on this subject. So, if anybody else has any insults for me, send them to me privately if you don't mind.

[Dustdevil]

Where the Hell in NC is this guy working, making patient care decisions on a whole 120 hours of training, without paramedic supervision?

[JakeEMTP]

Where the Hell in NC is this guy working, making patient care decisions on a whole 120 hours of training, without paramedic supervision?

Durham. Another place to add to the list.