Complex cardioversion?

[firefighter523]

Ruff, like I said in the past, you always have that rare case where the person does not want anything done. In 97% of the patients you will encounter, you already know what they want, they called 911. I am sorry for coming off aggressive to you. It did get a bit heated, I hold no grudges, that is ems. As far as throwing your letters at the end of your name at someone to gain respect, that is for the birds. You must earn respect, I don't care if you are the President. I once had a doctor ask me why I gave nitro to a pt with JVD, rales, and pedal edema, with a hx if CHF. He asked me if he complained of chest pain, the next words I heard from his resident was "get me 4 of morphine". The point I am trying to make is that we are all human, and there are 10% idiots in all ranks, even doctors. You get out of it what you put into it. I know many paramedics that will stand there ground in a 12 lead debate with any cardiologist.

[Just Plain Ruff]

fair enough fire but you still didn't answer my question as to how long you have been a medic.

I appreciate the fact that you are an agressive patient advocate. I like that.

take care be safe and god speed

[paramedicmike]

Great! Now that that's settled, can we get a lock on this thread?

[Thunderchild145]

Doc, with all due respect, I was talking about an EMERGENT situation. So you mean to tell me that is someone has an accucheck of 17 mg/dL, and is unconcious, you would be held liable if you didn't tell them that you are giving them an IV and sugar????

Unconscious pt, therefore implied consent.

... elderly male with difficulty breathing. On arrival, you find a 74-y/o male in severe respiratory distress. He has altered mental status and appears to need to sit up to breath. His wife reports he has a two-day history of progressive dyspnea much worse than his baseline, as well as a history of emphysema, atrial fibrillation (AF), CHF, and continued smoking.

The patient is cachectic, appears wasted, and has dry, flaky skin except around his lips, which are blue. Your assessment reveals significant suprasternal and intercostal retractions, absent breath sounds bilaterally, and use of accessory muscles. Vitals: BP 92/48; pulse thready and unable to count at fast rate; RR 44. Also observed is 4+ pitting pedal edema, extending to mid-calf, and mild abdominal distention.

A cardiac monitor reveals an unusually high tachyarrhythmia with an irregular rate of around 220. (Note: rates are usually significantly lower.) Due to the increased heart rate, it’s difficult to discern the underlying rhythm.

Conscious patient, and even with AMS is probably still able to make decisions. EXPRESSED consent is required.

[brock8024]

I will agree that we do have to do stuff to our patients in times of need. What I am saying is that no matter if we think they can hear us or not, we should still explain what we are doing to them. Yes on my patients that have a low blood sugar that I am giving glucose I still explain that I am starting the IV and what I am giving them. If I had to cardiovert someone I would still explain what was happening. I believe that we are all smart enough to multi-task and explain what we are doing when we are doing it.

I have never been told not to explain what I was doing. Heck I intubated a cardiac arrest patient and Was explaining everything. Did he hear me nope but did it hurt Nope. I believe that you can never go wrong with explaining things. We might know what a patient needs but that does not mean that we do not explain. If you believe that a patient does not hear you wait til you get sued for saying something

Now the one thing I want to know is why I was attacked. What did I say or do for Fire to tell em I should never practice in his state, and that he hopes that I am just starting out. We are all learning no matter if we have been doing this for 1 month or 30 years. I will graduate in may with a A.A.S 2 year degree. My school is the only nationally accredited school in oklahoma. I take great pride in what I learn and my job. I always act as a Professional. I do not see anything in my post that should have been attacked. So please humor me and tell me why you acted so unprofessional. Thanks

I was not bragging but I take great pride in my education.

[ERDoc]

Doc, with all due respect, I was talking about an EMERGENT situation. So you mean to tell me that is someone has an accucheck of 17 mg/dL, and is unconcious, you would be held liable if you didn't tell them that you are giving them an IV and sugar???? That is implied concent, and this is the same situation, it would be negligent if you waited for an answer from them. I want to reiterate, if the pat is aware of there surroundings and looking at you, of course I would let them know what is going to happen, I would do just that " Let them know" , not give them the choice, their life depends on the critical decisions we make. That is why we go to school, and put everything we have into education, to learn more and more everyday. Part of being a good provider is being decisive, it makes the pt more comfortable with you, and gives them the sense that they are in good hands.

I have dealt with a handful of critical pts that could NOT understand what I was saying to them, much less, they became flacid, and were on the brink of respiratory arrest, among other things. How the heck can anyone hold a provider liable for NOT telling them what you are going to do. YOU WILL BE HELD ACCOUNTABLE FOR YOUR ACTIONS IF YOU DON'T PROVIDE THE RIGHT THERAPY FOR THEM IN A TIMELY MANNER!! That is negligence and that is what you call CRIMINAL.

And Rid, If I have to see that you have done this for 30 years again in your text, I am going to puke!! Gloating is for CHUMPS!!

You are either flip flopping or missing the point. No one here is aruging that an unconscious pt should be treated under implied consent. You also do not need to tell them what you are doing, though it would be nice to do if they were conscious. The point that I have been making and seems to be missed is that even a hemodynamically unstable pt can still be A&OX3 and have the capacity to make their own decision. You are ethically and legally bound to get their consent before performing a painful and invasive procedure. If they tell you no, it will suck but you will have to sit there and possibly watch them go down the drain. Welcome to the world of medicine. You are obligated to make sure that they are making an informed decision and also present other possible treatments. This should include, "Hey, when you go unconscious, can I shock you then? How about when your heart stops?" Gets straight to the point and let's them know what will happen. One of the most important things you can get from a pt before they loose the capacity to make their own decisions is what their wishes are. Whenever I have someone that is circling the drain, I will do a brief assessment and then ask them, "If your heart stops or you stop breathing, what do you want done?" You now know what you can and cannot do. This is not some Orwellian state, we do not make decisions for our pts, we let them know what is appropriate to treat their problem, what the alternatives are and what the possible outcomes are. It is up to them to make the decisions, that is the humanistic approach to medicine that you seem to lack.

[Ridryder 911]

And Rid, If I have to see that you have done this for 30 years again in your text, I am going to puke!! Gloating is for CHUMPS!!

The only reason for stating such is because over the years of experience, (beginning when you were in diapers) is I have seen many of your type come and go (mainly go). As an educated person, I will not attempt to debate cardio pathophysiology with you or medical ethics and legal implications, as demonstrated from your posts you are not able to comprehend or digest such statements.

This is part of the problems of EMS and prime example of some our products produced by our current "training" methods and not being able to comprehend basic medicine and the diversity associated with it.

We have attempted to understand your implications from your posts and even agreed within special circumstances for allowance, however; those with apparent higher credentials, education and yes... even far more clinical experience was attempting to illustrate in basic terms to you is implications of care is not always black and white, and as well there are areas ...(gasp!) that might not be covered in the text you studied from, that might not have covered in depth and as well as should had been covered. This is the reason for forums is to attempt broaden education and mind sets that might be thought previously as gospel.

The debate of something over something this simple is ridiculous and if EMS really produced in depth practitioners, eight pages of debate would never had occurred.

R/r 911

[scratrat]

Ok this is really getting annoying now. Let reiterate it AGAIN. I simply stated from the beginning.... If at pt is CRITICAL, UBTUNDED, UNRESPONSIVE, and is ready to die, ie..... Low sugar, high sugar, increased ICP, anykind of shock, OD, unstable tachy dysrhythmia.... am I hitting them all? You then fall under IMPLIED consent!!!!! Not EXPRESSED, expressed being the words NO or YES coming out of the patients mouth. Did I mention that is EXPRESSED!! If before they become unresposive, I guess there is the RARE possibility that they will tell you they DONT want anything done. If that is the case and they don't have a DNR present, you must CALL MEDICAL COMMAND!!! I think I am fully aware of this RARE situation!!! If they DONT state the above mentioned statement and crap the bed, you MUST assume they want to LIVE!!! This is NOT so hard, is it??? This will NOT get you nor I in trouble and is the STANDARD of CARE folks!!!!

Call me whatever you would like, I don't care. I am my pt's best advocate all of the time. I will always tell them what I am doing, NOT ask them what they want, do you know why fellas, because they DONT know!!!!!!!!!!!!!!!!!!! We are the ones that must tell them, not ASK. If you tell them and they don't want it, then they sign the dotted line. Is this ENGLISH understandable.

Now I see where the problem lies fire. You are grouping senarios together which is causing people to think and reply the way they are.

Take the above example :If at pt is CRITICAL, UBTUNDED, UNRESPONSIVE, and is ready to die, ie..... Low sugar, high sugar, increased ICP, anykind of shock, OD, unstable tachy dysrhythmia.... am I hitting them all?

Well, if they're critical, that's not implied consent.

If they are obtunded, yes.

If they are unresponsive yes.

If they are ready to die, NO!

Low sugar, not necessarily.

High blood sugar, probably not.

Increased ICP, not by itself.

Shock, not necessarily.

OD, nope.

Unstable dysrhythmia, nope.

Not unless they are unconscious. Just because they are critically sick, doesn't mean it's implied consent. Obviously some of these things we certainly take for granted daily.

I think this is why so many people are getting angry with your statements, because it SOUNDS like you think that anyone who is critically sick warrants whatever treatment you deem necessary.

I know you don't care what I think, and that's fine. All I'm saying is, read it after you type it.

[firefighter523]

Thunder, Severe intercostal retractions with an altered mental status, and BP hovering around 90, with a rate of 220 WILL, get cardioverted in the field any day of the weak. AMS with severe respiratiory distress is an OMNIOUS sign of impending arrest, respiratiory or cardiac!!!

Brock, you WOULD NOT push lasix, give nitrates, or ASA for this pt. His rate is causing the resp distress. You must treat the cause of the problem, not the manifestations resulting from the problem!! His BP is TOO low for any calcium channel blocker, and I doubt you would get orders for any of them if you give any competent MD this report, especially Verapamil. I don't know what you use in your system, but that is what we use. Severe hypotension, and CHF are contraindications for Verapakill.

[Just Plain Ruff]

You still have not answered my question Firefighter523

how long have you been a medic?

One other question, you are touting how great your system is, just where do you work?

Either you didn't see my question or you are refusing to answer my question.