Paramedic Incompetence Question

[AMF]

IMHO, the answer is simple. You follow your protocols. If the primary decides not to follow protocol, you document it and let the primary take the consequences. If this patient can't protect his own airway, I'd consider intubation as well, but I'd want to use an actual ETT instead of a KT, Combitube, or LMA. If you think that the patient needs that advanced airway, doing an airway assessment might be a BIG priority...

When I as a paramedic, arrive on-scene, normally I want to get to the report and begin my assessment immediately. If a lower level provider does not want to give up care and I think the patient can benefit from a paramedic, I will take over. That could mean calling law enforcement to have that lower level provider ejected from my scene. Now if a lower level provider is appropriate to provide care, I will do my assessment and triage the patient back to the lower level provider. My documentation will reflect that.

If that lower level provider does not want to take care back from me, I am stuck with the patient.

There are very few times that I would steam roll over another provider. And there are very few times that I've ever had to do it. Those times that I have, it has always been a lower level provider that was not providing appropriate care.

If the other provider is at the same level as I am, I have to get medical control online to provide guidance. Fortunately have never had to do that.

Re: scene control, that answers some questions. Thanks.

Re: Airway, I'm not a paramedic. ETI is a paramedic-only skill. I rode with the patient, but they ran the call bls code 1. The paramedic didn't even report the lack of responsiveness until after he called in. Obviously, as an EMT student, I've been taught only the worse-case scenarios, which is why I'm asking: what is the least that could happen to warrant spinal immob at your companies?

 

[Aidey]

How do you board someone without kneeling (It filled the room)?

Protocol says:
Uncertain Mechanism of injury?
Acute Stress Reaction ---------> Board
Tenderness or pain on spine --> Board
CMS F'n Test failure -----------> Board
Basic Stroke Test failure ------> Board
Unreliable Patient --------------> Board
Else -----------------------------> Don't Board

He definitely fell. Bystanders (reliable) said he didn't have the laceration/contusion earlier that night. And him being combative wasn't a problem. He could barely keep his eyes open.

I agree that airway is a greater priority. If I were an ALS provider I would have used a blind airway. As it was, I was considering an OPA (but I was just the secondary).

I don't see how his fall wasn't at least questionably significant. He fell 4' on his head.

Um, what?

 

[Handsome Robb]

I think that was what the paramedic was thinking. I misread NVRob's post; he seems to be talking about a supply issue, which is not the issue here. It's our board anyways.

I would again ask: what is the baseline indication at your company/region/whoever sets your protocols for spinal immobilization?

I'm not lazy if that's what your implying. Also, we have plenty of supplies, the problem is taking units OOS to restock if every drunk person gets spinal motion restriction, which by the way is what we do, we don't provide spinal immobilization.

• Full spinal motion restriction should be provided for all patients who:
o Have midline cervical or thoracolumbar spinal tenderness or pain, pain
with gentle palpation, distal numbness, tingling, weakness or
paralysis, all with appropriate traumatic mechanism
o Have altered mental status or are under the influence of intoxicating
substances
o Have any other condition that in the paramedic’s judgment is reducing
pain perception
o Are under the age of 12 with appropriate mechanism
o Present with a language barrier making the assessment and
interpretation of pain or injury difficult
o Pain with active range of motion of neck

There ya go. Our medical director also allows us to use our judgment to make decisions.

 

[systemet]

I'm not sure I'd be rushing to RSI this guy based on the information given. Obviously we need a bG. If they're oxygenating / ventilating ok, and they're maintaining the airway, I think we can wait on that. Just an opinion --- it's always hard to get a decent impression of how the patient presented from a brief description on-line.

I think the issue here is whether c-spine is indicated. And that rests on whether you feel you have a positive mechanism or not. It's a little hard to know in this situation, and I think even as a medic, with an unknown mechanism, altered LOC and obvious facial trauma, I'd be pretty keen to board this guy, even if I suspect the probability of an unstable fracture is pretty ridiculously low.

If you believe there's a mechanism, neither NEXUS nor Canadian C-spine rule can be applied. If you feel comfortable saying there's no mechanism, then you can avoid the whole issue. Being honest, I think we could probably avoid boarding most of these patients without missing too many fractures. And most of the fractures we miss will likely be stable, or the damage already done. But I don't think most of us are willing to take the risk, or accept the potential liability. Sometimes it's easier to over-treat in this situation.

Of course, it's not the same everywhere. Just in randomly travelling around Europe I've seen two patients I would have c-spine'd, that the local EMS crews haven't been concerned about. One guy got hit by a seadoo, fractured jaw, spitting up teeth, brief period of unconsciousness / apnea, but GCS 14 after having been removed to dry land. No c-spine applied. Another guy who took a header off a bicycle at a fair speed, suturable laceration and decent hematoma minutes afterwards, with confusion and true repetitive questioning, same decision. Not what I'm used to --- but c-spine practices vary in EMS systems across the world.

 

[Veneficus]

I absolutely hate spine boards...

Background:
I work for a QRS, meaning we don't transport. When we get dispatched, the neighboring ALS service, which usually runs double paramedic, gets dispatched as well. This service is one of the best in North America; I did my basic ride time with them and have nothing but the utmost respect for them..

I love this, it is like saying "my friend is (race x)" before telling a racial joke.

I'm running secondary on a call for an intox male in need of evaluation. We get there and the scene is covered in urine (the entire dorm room). Security found the patient in "kowtow" and brought him up against the bed (violating c-spine)..

What kind of violation is c-spine? Felony? Bad touch?

to try to wake him before we got there. Bystanders report that the patient was found in the "kowtow" position by his bed

Please, when discussing medicine or medical care with a group of international participants, the internationally accepted medical terminology is generally helpful.

3' to 4' feet off the ground.

Aka, not far if he fell at all.

Also, kids and drunks have this amazing, bouncing, injury avoidance capability.

Patient presents with a laceration on his forehead several cm in diameter.

Diameter? It was circular? Or simply a straight laceration? Exactly how long was it? Was it bleeding? What kind? How much?

He is A&Ox0 with a GCS of 9 (5 Motor, barely; 2 Vocal, barely; 2 Pupilary, but fighting it

Forgive me, but what does this mean?

Paramedics get on scene as we discuss boarding him. The primary paramedic is apathetic ("sure, whatever") but insists that he's not carrying the patient.

I am not surprised.

I know he's in the wrong about boarding him; I'm not really asking about that.

Do you really think so?

Perhaps you may consider the reason your (and most EMT-B) protocols on immobilization are:

1. outdated
2. put in place because basic level providers largely do have the education to decide when to use or not use (allow me to be generous) spinal motion restriction?

In fact, even outside EMS, most low positions which require such low level training do not allow much decision making.

But my partner then says, in essence, "Obviously you out rank us, but we'd really like to board him." Is that true? I've always treated the paramedics as ALS intercepts. They're not part of our service, so the patient isn't theirs until we transfer care.

I think you are getting too hung up on the whole "rank" thing.

Patient care is not always about rank. It is about doing what is best for the patient.

Every drunk person who falls down and goes boom does not require a backboard. If the guy was 6 feet tall and fell from standing his head would have traveled farther.

Incidentally, what exactly was the mechanism of c-spine injury you were considering? Flexion? Extenstion? Rotation? Lateral compression? Hyperextension?

What would cause each of those mechanisms?

Do you think that the foreces were serious enough not only to fracture the body of a vertabrae (not just a spinus or transverse process) as well as damage the muscles and other soft tissue suporting the spine, beyond their ability to do so?

Do you think there was direct spinal cord insult or perhaps ischemia due to compartment restriction of of inflammation?

If the latter, do you think putting a ridgid device that restricts compartment expansion would help?

Rules are more like guidlines and some level of rational sense needs to be applied.

In the absence of the ability to make decisions, you follow your rules not because they are best, but because you have no other option. People who are not bound by such rules are not incompetent.

To reiterate, nothing against paramedics. Most of the ones I interact with are PIFTs with college degrees. They are well-experienced and use expensive procedures sparingly and don't mess up.

:rofl:

Who are these masked gods of medicine?

Everyone messes up, it is part of being a human being. The real trick is to minimize it and recover when you do.

Onto this airway thing I read snippits of...

Did somebody suggest an ET or combitube? For what?

I also recall mention of an OPA. given the patient was sitting up and still breathing at one point, an NPA might be a better idea.

Guys (and gals) please. Not every patient is in critical condition. Most of them are not. If you got drunk at a party and fell off of a bed, do you really think the solution is to be strapped to a backboard and have a plastic tube stuck in your throat? "just in case?"

I guess pressure sores don't mean much to you, nor aspiration or foreign body obstruction.

When that patient is tied down on their back, do you really think you can manage their airway and stop them from aspirating vomit, Because you will have to be really quick to turn that board on its side before you see the vomit and a patient takes another breath.

I can offer my assurance if your service goes around thinking RSI and a tube is the proper solution to every drunk who might vomit, you won't be doing RSI much longer for a number of reasons.

If we consider the next step, which is the ED, what about the cost of your CT to clear your spine?

How many beds does your hospital have to babysit drunks all night?

How many drunks do you have that would going to those hospitals in any given night?

Have you ever heard of this?

http://en.wikipedia.org/wiki/Dunning-Kruger_effect

I am not trying to be a jerk, but you seem kind of new. So rather than get into a rant or discussion on who is right or wrong, perhaps a better question would be "why" did any given actions, treatments, etc occur or not occur?

Granted, something are right or wrong. But they are few.

 

[DrankTheKoolaid]

re

This pretty much negates any further discussion.

http://wishididntknow.com/2011/11/1...f-4-foot-high-dorm-bed-paralyzed-sues-school/

Like it or not protocols are there for a reason, an altered ETOH+ patient is NOT a good historian and needs to be placed in full spinal precautions.

 

[hippocratical]

Veneficus, that was an impressive smackdown of a reply, and while I agree with much of it, I'm sure others are going to get pissed about it.

On a separate note though:

http://en.wikipedia.org/wiki/Dunning-Kruger_effect

That's pretty awesome. I wondered why I hadn't heard of this (as a Psych major myself) but it seems it was published just after I graduated. I especially like this tidbit though:

"Dunning and Kruger were awarded the 2000 Ig Nobel Prize in Psychology for their report, "Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments"

How I would love to have been awarded an Ig Nobel! It's a fantastic ceremony I hear...

[EDIT] Oh and I love this bit:

it is clear from Dunning's and others' work that many Americans, at least sometimes and under some conditions, have a tendency to inflate their worth.

;-)

 

[JPINFV]

This pretty much negates any further discussion.

http://wishididntknow.com/2011/11/1...f-4-foot-high-dorm-bed-paralyzed-sues-school/

Like it or not protocols are there for a reason, an altered ETOH+ patient is NOT a good historian and needs to be placed in full spinal precautions.

Call me when a verdict comes back.

 

[DrankTheKoolaid]

re

No verdict needed, this shows exactly why these protocols are in place. Though this type of incident is certainly the exception and not the rule, it is why protocols are in place.

Verdict? What verdict if the family wanted to sue EMS it would have been cut and dry? If their protocols say +ETOH is an inclusion into the spinal immobilization algorithm then it is a cut and dry case. They did not follow well established and universally accepted protocols and the patient may have been placed in further harm because of it. But It appears they went after the bigger pockets and went after the institution instead. But the point is the same, Think if was YOUR company employee that failed to care for this person per protocol and had a poor outcome like this possibly worsened by that crews negligence..........

From a risk management stand point, if it was a paid employee they would be hung out to dry by our own insurance and would be left to defend themselves and be both financially and legally responsible. And heaven help ya if you did not have you own malpractice policy.

 

[mycrofft]

To clarify my little reply

What is a kowtow position? I finally understood, the bed is about 4 ft off the ground (same as that one in the news article), not the kowtow position.
As for not kneeling in urine, stay off your knees, just like when brains or feces are scattered about. Or broken glass. Or drag a blanket or pillow down and use that.
Still and all, follow for protocols unless there is an overriding necessity they don't cover. Including pecking order.

 

[JPINFV]

No verdict needed, this shows exactly why these protocols are in place. Though this type of incident is certainly the exception and not the rule, it is why protocols are in place.

You're telling me that if he wouldn't have followed protocols then he wouldn't be sued?

As far as protocols in place, are you suggesting that protocols should be followed like a cookbook without thought by the individual providers?

Verdict? What verdict if the family wanted to sue EMS it would have been cut and dry? If their protocols say +ETOH is an inclusion into the spinal immobilization algorithm then it is a cut and dry case. They did not follow well established and universally accepted protocols and the patient may have been placed in further harm because of it. But It appears they went after the bigger pockets and went after the institution instead. But the point is the same, Think if was YOUR company employee that failed to care for this person per protocol and had a poor outcome like this possibly worsened by that crews negligence..........

Everything is situationally dependent. I can easily think up specifics in a case like this where not immobilizing the patient would be completely justified. This is ignoring, of course, the fact that spinal immobilization has absolutely zero evidence supporting it. It's akin to modern day blood letting.

Besides, you're still missing proximate cause. Prove that the lack of immobilization is what caused the damage? How often do you see patients laying in the ER on a spine board who has been worked up?

From a risk management stand point, if it was a paid employee they would be hung out to dry by our own insurance and would be left to defend themselves and be both financially and legally responsible. And heaven help ya if you did not have you own malpractice policy.

What's the purpose of having malpractice insurance if you're just going to cut employees loose if they are sued?

 

[Veneficus]

No verdict needed, this shows exactly why these protocols are in place. Though this type of incident is certainly the exception and not the rule, it is why protocols are in place.

Verdict? What verdict if the family wanted to sue EMS it would have been cut and dry? If their protocols say +ETOH is an inclusion into the spinal immobilization algorithm then it is a cut and dry case. They did not follow well established and universally accepted protocols and the patient may have been placed in further harm because of it. But It appears they went after the bigger pockets and went after the institution instead. But the point is the same, Think if was YOUR company employee that failed to care for this person per protocol and had a poor outcome like this possibly worsened by that crews negligence..........

From a risk management stand point, if it was a paid employee they would be hung out to dry by our own insurance and would be left to defend themselves and be both financially and legally responsible. And heaven help ya if you did not have you own malpractice policy.

You know what that lawsuit looks like?

Desperation.

The kid was stupid and wants somebody else to pay for it.

Suing the school for not putting handrails on a bed in a college dorm?

I doubt even the OJ jury will swallow that one.

I want to see how they prove the actions of the EMTs resulted in the actual harm or loss and not the initial strike.

I would like to see the expert witness explain how they could tell the difference from the damage caused by the fall, the alcohol intox, and the actions of the EMS persons.

I also didn't see what the "reasonable attorney fees" are or if it is Pro Bono (which i somehow doubt)

As well, how many lawyers do you think would waste time suing somebody who makes at or near minimum wage.

If the defense got a seperation of the university from the EMS volunteers, I'll bet that suit would be dropped. Dewey, Cheatum, and Howe really doesn't want 33% of nothing. Just like they wouldn't want 33% of the $8 an hour the pro EMT makes.

This kid is messed up only because his parents didn't teach him to act responsibly.

If he is under 21 (or the local drinking age) his case is probably already over. I am sure most states have laws against seeking damages while engaged in the commiting a crime.

It sounds to me like the lawyer just wants a quick cash settlement, Which will come nowhere near the charity medical costs, because I doubt very much the doctors and facilities treating him think they ever will actually recoup the costs, much less the bill.

And imagine the argument I would formulate if I was a lawyer.

You cannot eliminate the threat of being sued, it is pointless to try, and more pointless to think inducing panic (a crime) over it will change anything.

Verdicts count.

 

[mycrofft]

It IS this incident, isn't it?

http://emtlife.com/showthread.php?p=357613#post357613

 

[DrankTheKoolaid]

re

Your missing my whole point. Do you think these EMS outfits have endless funds and lawyers on retainer? I think not.

Train your people to follow protocols as given by your medical director. Any variance from protocols why would a company waste valuable resources defending them when they have simply become a liability.

And no, I do not believe in cookie cutter blindly following protocols either. But time and time again altered and ETOH+ patients have proven to be poor historians and unreliable on exam. These cases both show it.

And your right the kid did the damage himself and EMS is really not to blame. But when something like this goes up in front of a bleeding heart jury anything can happen....................

 

[JPINFV]

I think you overestimate the ability of protocols to protect you from lawsuits.

Any variance from protocols why would a company waste valuable resources defending them when they have simply become a liability.

So paramedicine is not a profession, but a simple technical trade.

 

[Veneficus]

I think you are missing my whole point

Your missing my whole point. Do you think these EMS outfits have endless funds and lawyers on retainer? I think not.

Train your people to follow protocols as given by your medical director. Any variance from protocols why would a company waste valuable resources defending them when they have simply become a liability.

Lawyers sue deep pockets.

They do not waste time on EMTs, they want organizations with insurance and/or lots of cash.

A coperation or organization named in a lawsuit doesn't need to defend the employee. They need to defend themselves. That is why lawyers don't simply name EMS professionals.

It would be a hollow victory. The EMT couldn't meet the resources, but couldn't pay the judgement either. In civil law "I'm sorry I messed up" is said with a payout, not with a judgement.

Follow the money.

 

[DrankTheKoolaid]

re

No i completely understand they protect you from nothing. But at least if you followed established protocols you have have some leg to stand on. And when a expert witness gets up and is asked if they followed standard treatment guidelines they would at least back the provider by saying "Yes this patient was treated per the providers training and established protocols as set by his / or her medical director". People / entities can be sued for anything at anytime and we can thank bottom feeder lawyers for it..................

 

[Veneficus]

No i completely understand they protect you from nothing. But at least if you followed established protocols you have have some leg to stand on.

I seriously urge you not to think this way.

Whether you follow a protocol or not, if you do something that actually causes demonstratable harm, you are responsible.

And when a expert witness gets up and is asked if they followed standard treatment guidelines they would at least back the provider by saying "Yes this patient was treated per the providers training and established protocols as set by his / or her medical director".

I doubt that very much. Nobody is going to call an expert witness that deosn't back their case.

The plantif will find an expert witness to testify you did something wrong because they have to show cause.

Your defense will call their own expert who will bolster their case.

Eventually it may come down to a third party witness, who will be asked if in their opinion the treatment caused harm, not whether or not you follow protocol.

If 10,000 witnesses testify you follow protocol and even 1 can show that following that protocol lead to damage, it won't matter if that protocol was penned by The divine being of your choice.

 

[JPINFV]

 

[AMF]

I love this, it is like saying "my friend is (race x)" before telling a racial joke.





What kind of violation is c-spine? Felony? Bad touch?




Please, when discussing medicine or medical care with a group of international participants, the internationally accepted medical terminology is generally helpful.



Aka, not far if he fell at all.

Also, kids and drunks have this amazing, bouncing, injury avoidance capability.



Diameter? It was circular? Or simply a straight laceration? Exactly how long was it? Was it bleeding? What kind? How much?




Forgive me, but what does this mean?





I am not surprised.




Do you really think so?

Perhaps you may consider the reason your (and most EMT-B) protocols on immobilization are:

1. outdated
2. put in place because basic level providers largely do have the education to decide when to use or not use (allow me to be generous) spinal motion restriction?

In fact, even outside EMS, most low positions which require such low level training do not allow much decision making.





I think you are getting too hung up on the whole "rank" thing.

Patient care is not always about rank. It is about doing what is best for the patient.

Every drunk person who falls down and goes boom does not require a backboard. If the guy was 6 feet tall and fell from standing his head would have traveled farther.

Incidentally, what exactly was the mechanism of c-spine injury you were considering? Flexion? Extenstion? Rotation? Lateral compression? Hyperextension?

What would cause each of those mechanisms?

Do you think that the foreces were serious enough not only to fracture the body of a vertabrae (not just a spinus or transverse process) as well as damage the muscles and other soft tissue suporting the spine, beyond their ability to do so?

Do you think there was direct spinal cord insult or perhaps ischemia due to compartment restriction of of inflammation?

If the latter, do you think putting a ridgid device that restricts compartment expansion would help?

Rules are more like guidlines and some level of rational sense needs to be applied.

In the absence of the ability to make decisions, you follow your rules not because they are best, but because you have no other option. People who are not bound by such rules are not incompetent.




:rofl:

Who are these masked gods of medicine?

Everyone messes up, it is part of being a human being. The real trick is to minimize it and recover when you do.

Onto this airway thing I read snippits of...

Did somebody suggest an ET or combitube? For what?

I also recall mention of an OPA. given the patient was sitting up and still breathing at one point, an NPA might be a better idea.

Guys (and gals) please. Not every patient is in critical condition. Most of them are not. If you got drunk at a party and fell off of a bed, do you really think the solution is to be strapped to a backboard and have a plastic tube stuck in your throat? "just in case?"

I guess pressure sores don't mean much to you, nor aspiration or foreign body obstruction.

When that patient is tied down on their back, do you really think you can manage their airway and stop them from aspirating vomit, Because you will have to be really quick to turn that board on its side before you see the vomit and a patient takes another breath.

I can offer my assurance if your service goes around thinking RSI and a tube is the proper solution to every drunk who might vomit, you won't be doing RSI much longer for a number of reasons.

If we consider the next step, which is the ED, what about the cost of your CT to clear your spine?

How many beds does your hospital have to babysit drunks all night?

How many drunks do you have that would going to those hospitals in any given night?

Have you ever heard of this?

http://en.wikipedia.org/wiki/Dunning-Kruger_effect

I am not trying to be a jerk, but you seem kind of new. So rather than get into a rant or discussion on who is right or wrong, perhaps a better question would be "why" did any given actions, treatments, etc occur or not occur?

Granted, something are right or wrong. But they are few.

I am very new, and I appreciate what you're trying to say. Though, at least in Maine, it doesn't really matter if you're a paramedic or not. You follow protocols, because that's what's legally expected of you.
Generally, when an EMS provider puts something in quotes, it's because they are the words of someone else. I arrived after the patient was moved.
This patient was critical. He was not sitting up by himself. It took several sternal rubs each time for him to open his eyes. His breathing we fine (<12 though), so I was fine with him not being intubated.
He was on the bed, and then he wasn't. His head was on the ground. He can't move. He had a laceration/contusion (an elipse, with diameters 3-4 cm by .5-1 cm) that wasn't there before. Not sure why you think he didn't fall.

Your questions make me think. I like that. But as an EMT, thinking is extra. We are legally bound to do what a little book tells us we have to do. My question was really about rank. I didn't think there would any argument about the treatment.