Help me settle a debate

[HERBIE1]

If a person, even well known, has a frame of mind where they consider an overdose to be acceptable. Then they aren't in a state where you can trust them. The other factors just bolster the idea that waiting is better. Yes, it's possible that going in, not waiting, and taking the patient could save their life. It's also possible that while waiting, the patient may die. Then, it's also possible they really want to die, and will kill you, to ensure nobody stops that plan. That's the only flaw in the plan of attempted suicide cases, the ones who really don't want to die; many times do die, because help didn't arrive in time. But who are we to judge, by dispatch info, whether a person was serious or not, or if they're dangerous?

Had a case just after I became an EMT. A person shot themselves in the chest, and did not want to die. The spouse called 9-1-1, begging for help. Police arrived, ambulance, helicopter, paramedics all on hand. The patient wouldn't give the gun to police. The patient was conscious, alert, talking, highly intoxicated -- and holding a gun. Until [the pt.] passed out, [the pt.] was waiving the gun around. Maybe [the pt.] didn't understand what was happening, but was the patient able to be trusted? [the pt.] was drunk, and armed. Only one of which, IMO, is required to lose trust. The patient bled to death, with a gun in their hand. I wasn't going to lose my life to find out if [the pt.] was done shooting or not. According to the history, neither alcoholism nor depression were ever issues in the patients life, an apparent one bad day incident. Of course, who knows what the patients side of the story was.

But how does a person who OD's a danger to you, or justify a delay in your response? Will they be upset and angry? Maybe, maybe not, but anyone who's been doing this job for more than a day knows what it's like to deal with someone who is under the influence. The point is, SOMEONE called for EMS- and most often it's the patient, after they had a change of heart. Obviously if a person has a weapon that is NOT a safe scene and until that person is disarmed- or dead- you have no business being anywhere near them. I think a little paranoia is a good thing, but it also should not paralyze you and prevent you from doing your job.

I've had thousands of suicide gestures/attempts and not once did anyone want to take me with them. They may be angry that you are there, angry that their attempt was not successful, angry that someone called to foil their plan, but nobody has ever tried to harm me because I was their to foil their plans. I've had plenty of people beg me to let them die, but never have I been threatened by such a patient.

As for trust- I don't trust ANYONE-sober, sane, drunk, young or old. Just like driving with lights and siren, you assume that your rig has a bulls eye on it and everyone is aiming for you. You assume that the person in front of you will do the exact opposite of what they should do. When carrying a little old lady out the door or down the stairs in a stair chair, you assume she will ignore your instructions and reach out and grab the doorframe or railings potentially injuring you.(I have a friend who's career was ended in exactly that manner- the elderly patient grabbed a doorframe as they were going through it, his neck was torqued, and he blew out 2 cervical vertebrae.) It's not intentional or malicious, it's just you cannot trust anyone to do what you instruct them to do.

You take whatever information you can from dispatch, any prior knowledge you may have of the area, and take that into consideration when you arrive on the scene. You constantly assess the situation, monitor the potential hazards, and then if you see a credible threat to your safety, you back off and wait for help.

[DwayneEMTP]

I'm with you Herb...it's a statement oft repeated by students, as they've heard it in school, "If they'll kill themselves then they'll have no problem taking them with you!" But I've also never seen any sign of this.

Also in my mind a call to an OD is not, alone, reason to delay a response. There may be many things I see on the way, or upon arrival that will cause me to do so, but if I've not been requested to hold for the LEOs then I'm going to check it out.

On TV these scenes are always filled with giant, heavily muscled black guys with guns and ominous stares. My experience is that the scene is most often filled with a bunch of sad, lost, damaged people that can sometimes make a lot of noise, but are rarely interested in any type of conflict. Actually, even more common everyone but the person that happens to be screwing the OD is usually gone...I've just rarely seen these scenes as generally dangerous just on their face.

Now, the flip side, as I'm feeling very bipolar tonight, is that the OP did state that the dispatched call led to the feeling that the scene had the 'potential for hostilities' which changes things. Someone at the scene, or someone taking the call, or someone responding either had information, or recognized the address, or had their head up their asses....any way it works, if the call was dispatched in a way that would lead you to believe that it's dangerous, then you need to hold. That is the 'absolute' advice.

Having said that, I've gone into scenes where I've been asked to hold. One is a guy that kept having OD/hypoglycemia issues. He'd get completely obliterated on his meds, forget to eat, his mentation would change and he'd end up eating a shitload of his narcs thinking that that was going to help.

Seemed like a good guy, and it stumped the hell out of me. He had a drunk neighbor that always called and would yell things at us when we were there like, "I love him man! You fucking help him or I'll kill you! I mean it! He's like my brother, fucking help him or I'll kill you!"

I ran on him maybe, 15 times in a month. He was harmless. If he, and another 20 buddies just like him attacked all at once I could have kicked their asses without having to interrupt starting my IV. But we always found the patient in really, really bad shape.

Dispatch was forced to tell us to hold because of the nature of the call and the call contents, Kudos to them, but I knew better.

Scenes are dynamic. I had information that even when I'd told them of it they were professionally obligated to ignore. Very few things are black and white.

It turned out, and I verified this from the ER, that his narc AND insulin meds had been filled incorrectly giving him doses of each that he was not used to causing him to misuse them.

But, as always, the bottom line is, if you have any reason, or as Wendy said, any sense, that things might be froggy, then you have to wait. That's just good sense..

Dwayne

[romneyfor2012]

I hate to sound like crotchity, but is this more about the location than the call ? Does your partner equate indian reservation to poor, thus has a fear that he would not have if responding to mansion in a white neighborhood ? Now before everyone gives me negative scores, ask yourself how often you ask for PD on medical calls in affluent neighborhoods (not trauma or violent calls).

Personally, I would have been fine not asking for PD. I frequently went into some very dangerous neighborhoods, I found that if you treated them and talked to them like they were your family, I had no problems. But others who came storming in as a white authority figure, looking down their nose, routinely needed PD to save their ass.

Edited November 19, 2011 by romneyfor2012

[Siffaliss]

I hate to sound like crotchity, but is this more about the location than the call ? Does your partner equate indian reservation to poor, thus has a fear that he would not have if responding to mansion in a white neighborhood ? Now before everyone gives me negative scores, ask yourself how often you ask for PD on medical calls in affluent neighborhoods (not trauma or violent calls).

Personally, I would have been fine not asking for PD. I frequently went into some very dangerous neighborhoods, I found that if you treated them and talked to them like they were your family, I had no problems. But others who came storming in as a white authority figure, looking down their nose, routinely needed PD to save their ass.

Socioeconomic problems are everywhere, not just in non-white neighborhoods. Sure, statistically there is more crime in low income neighborhoods, however a knife to the body will hurt just as bad in a mansion as it would in a ghetto. I am color blind, and my job is to treat and go home at the end of each shift.

[rock_shoes]

At this point I think we need to give the OP a chance to clarify what information they had prior to arrival at the call as this seems to be the primary bone of contention.

[DFIB]

I hate to sound like crotchity, but is this more about the location than the call ? Does your partner equate indian reservation to poor, thus has a fear that he would not have if responding to mansion in a white neighborhood ? Now before everyone gives me negative scores, ask yourself how often you ask for PD on medical calls in affluent neighborhoods (not trauma or violent calls).

Personally, I would have been fine not asking for PD. I frequently went into some very dangerous neighborhoods, I found that if you treated them and talked to them like they were your family, I had no problems. But others who came storming in as a white authority figure, looking down their nose, routinely needed PD to save their ass.

Location means a lot. A call to a second class shag hotel means crack heads whores and pimps. But location is not everything. Location doesn't mean more than all the other factors of scene safety. There are many things we consider before entering a scene. Some neighborhoods have strict leash laws; others have pit bulls in every yard. Poor doesn't mean violent. Poor doesn't mean criminal.

The OP states that "The residence looked dilapidated and shabby". What does that say? and the partner didn't like the location. I mean the partner might buy his pot from that house or know some other info he doesn't want to disclose. There are some areas that LE will not enter or patrol after dark so, at least for me location is important.

I mean who really ever knows. I have to discipline myself to be safe because my inclination is to ignore the signs or to figure I can handle it. Safe is better although I often don't follow my own advice.

I don’t follow my own advice because as Dwayne said, I know my area and can make a reasoned decision about people and how they live, react, and behave.

[Happiness]

I think in my mind it comes down to the fact the partner didnt want to enter for what ever reason. I have refused only once to go in a residence until RCMP have cleared the scene because like Herbie I know my community. The other fact that should be noted is the fact that the residence itself could have a potential hazard, alot of homes here have not been kept up and there are those I will not go into because I dont want to fall through a floor.

[DwayneEMTP]

...I think in my mind it comes down to the fact the partner didnt want to enter for what ever reason...

Excellent point! I have a good friend that's a flight medic and he once told me that on the helicopter it's, "Three to go, one to say no."

I think this is a great rule unless you're partnered with a real pussy, or someone that will play the 'safety' card in order to sit and do nothing instead of running calls...

Dwayne

[BEorP]

Me and my partner have been in argument for the last few days. I was wondering if some of you could lend your opinion.

We work on a native reservation in Northern Ontario. We were paged out sometime between 5-6am for a drug overdose. The only other info that I remember was that the patient was 37 and female. My partner insisted that we wait until the police cleared the scene before we went in. I felt comfortable going in without them. He contends that given the fact that we weren't familiar with the residence, as well as the time of day and the nature of the call (potential for hostility), it was unacceptable to enter before the police. I maintained that given the potential seriousness of the call, that decision was at the paramedic's discretion. In short, it's not a black and white, yes/no answer.

Your thoughts?

Good question and it is an important discussion to have. The first point that is important to understand is that at least some people's interpretation of Section A of the General Standard of Care in the BLS Standards indicates that we need to actually approach a scene to determine it is unsafe (rather than simply deciding that something doesn't sound right from dispatch info). Obviously this is not what happens in practice across our province, but understand that staging without having a specific concern for your safety may put you at risk if the MOH investigates afterwards (thinking specifically of the June 25, 2009 incident in Toronto).

My personal opinion is that many paramedics stage too often. The vast majority of the time that we to wait for police, we end up entering a scene that is quite tame. Surely we could be smarter about how we do it without endangering ourselves. That being said, I will never question the judgement of my partner. We have all had different experiences and they may be more knowledgable about the community. If they want to stage, we stage, even though it may not be what I would have done if it were solely my decision.

As one example of overuse of staging, it seems as though some paramedics will never enter a scene without police where a patient is drunk. I think that this is unreasonable. You need to consider all of the call details. One call that sticks out in my mind was in a rural community where we were paged out for someone who was drunk. Our supervisor suggested that we stage and wait for police, but upon getting the full story from dispatch the patient was a long time alcohol abuser who had finally agreed to get help. Yes, he was drunk. No, he wasn't entirely cooperative, but he certainly was not violent and wasn't a risk to us. And even if he got violent, his current state would have allowed him the coordination to chase after me.

This leads to my final point. If a patient or bystander gets violent, get out! It should be that simple. For some reason, it seems like time and time again paramedics end up in a fight with a patient or someone on scene after being attacked. They press the emergency button but do not make any real attempt to remove themselves from the situation. Unless they are holding you there or blocking your only route of egress, there is no excuse for not getting out.

But to get back to your initial question, I don't know your community (or how safe it typically is), but I would think that not knowing of that house is probably a good thing. So in short, I agree with you that I would be comfortable entering without police. That being said, I understand that a partner could have a concern and I wouldn't argue with them on that.

[Richard B the EMT]

I went back to review the first posting in this string. I also read, quickly, the entire string, but will probably repeat other postings.

1) I am unaware of automatic dual agency responses in the area in question, as the area is unidentified. If certain calls elicit a dual response of EMS and the LEOs, both sides should be aware of what their respective responsibilities are, in relation to the other side.

2) Posting 1 never stated dispatch information indicating a violent patient, or if the LEOs had been dispatched.

3) If dual agency, does the EMS have standing orders on those "particular" call types for the EMS to "stage" until the LEOs clear as safe?

4) I, and past partners, have listened to that little voice saying "someting is off, here." I know I have requested NYPD on one call where there usually would not have been LEO accompanyment, proved me to just be nervous, but the responding LEOs understood.