Doctors as patients

[usalsfyre]

I'm curious where in the EMT curriculum/local protocols it gives you the authority to impose your will on competent patients....

 

[med51fl]

What I don't understand is that if they don't want any treatment, then why call. I ran on a doctor (GP) once that called for chest pain, but refused the Aspirin, nitroglycerin, and oxygen. My question to him was "why did you call?" His response was "because I am having chest pain." Doesn't make sense now and it didn't then.

All I can say is "sign the refusal here" and document everything the PATIENT is refusing.

 

[bigbaldguy]

When we transferred care to the helicopter crew, my partner started to give the report, then stopped and asked the doc/patient to continue. She told me later this was to give him a small sense of control in a scary situation. It did seem to help him. And the report was excellent... though a little too inclusive. I believe he was still talking as they got off the ground.

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That's actually a very good idea. Being on the other side is tough for medical providers which is probably why they make lousy patients.

 

[usalsfyre]

What I don't understand is that if they don't want any treatment, then why call. I ran on a doctor (GP) once that called for chest pain, but refused the Aspirin, nitroglycerin, and oxygen. My question to him was "why did you call?" His response was "because I am having chest pain." Doesn't make sense now and it didn't then.

All I can say is "sign the refusal here" and document everything the PATIENT is refusing.

He may well have taken ASA PTA and be aware that NTG and oxygen have no positive effects on outcome....

The last line is absolutely the appropriate response. Do you know how to provide true informed consent?

 

[bahnrokt]

I can almost assure you if you offered me that choice you would be hearing from the the state/local EMS licensing agency regarding threatening abandonment. This is an entirely reasonable request, and "because I said so" is not an acceptable answer.

I can't force treatment on a pt. But I am not going to let his refusal put me in a position where I am then expected to do something potentially dangerous to his daughter (move her w/o c-spine stabilizaion). The next step isn't abandonment, the next step is getting him on the line with med control and letting him hash it out with a doc. If I put a fall victim with a significant head injury in my rig without a collar or board and suddenly she can't feel her feet... I don't care what I have the guy sign on scene, its still my name on the pcr and my *** on the line.

There can only be 1 person in charge of patient care on your ambulance. If a pt or family member has decided they need to run the show you must be able assert yourself in a professional manor.

 

[Aidey]

It is more dangerous to put her on a back board then leave her off of it. Since when does a head injury mean spinal cord damage? We don't backboard stroke patients....

Oh and the next step would actually be listening to the patient's guardian rather than wasting everyone's time and letting her sit out in the cold. People are allowed to refuse interventions, even if refusing them may be detrimental (in your eyes). Just look at the Jehovah's Witnesses and blood transfusions.

 

[Tigger]

I can't force treatment on a pt. But I am not going to let his refusal put me in a position where I am then expected to do something potentially dangerous to his daughter (move her w/o c-spine stabilizaion). The next step isn't abandonment, the next step is getting him on the line with med control and letting him hash it out with a doc. If I put a fall victim with a significant head injury in my rig without a collar or board and suddenly she can't feel her feet... I don't care what I have the guy sign on scene, its still my name on the pcr and my *** on the line.

There can only be 1 person in charge of patient care on your ambulance. If a pt or family member has decided they need to run the show you must be able assert yourself in a professional manor.

If the patient says don't not do something to them and you do it, you've failed your patient. You could also theoretically face legal issues for asserting yourself in such a way. And if your reason in the first place is "because I said so," well then we have a problem. CYA is never a reason to use some sort of intervention on a patient, you need to be able to justify it medically as beneficial.

 

[Aidey]

There can only be 1 person in charge of patient care on your ambulance. If a pt or family member has decided they need to run the show you must be able assert yourself in a professional manor.

Oh, and I want to see how well that works for you the next time you have a very special needs child with some rare disorder that the parent is an expert in because they had to learn how to care for the child.

 

[CANDawg]

Oh, and I want to see how well that works for you the next time you have a very special needs child with some rare disorder that the parent is an expert in because they had to learn how to care for the child.

Day to day medical care for a chronic condition and emergency stabilization are two different things. They may be an expert in the condition (or as much of an expert you can be having self-trained via the internet), but EMS professionals are experts in stabilizing patients for transport to hospital. They need to understand that you know what you're doing.

Inform them, accept their advice, but unless they outright refuse an intervention (and have the authority to do so), make the decision yourself.

 

[Aidey]

We are not experts in all conditions, and chances are the parent has been through multiple different emergencies before. If they tell me not to do something, or use a certain medication you bet your arse I'm not going to do it without an exceptionally good reason and probably on line medical direction.

The use of adenosine in WPW is one of the more common situations where this could come up. The "conventional" emergency treatment will probably kill the patient.

 

[usalsfyre]

I'm a paramedic. I've got a bit of experience and credentialing behind me. My name and numbers are open for everyone to see. In addition, I can provide references to board members who know me and can vouch for me. In addition to all of this, I am dad to a 3 year old autistic some with some other (minor, but still possibly requiring emergent care at times) health problems. Some of the statements I read below are insulting, arrogant, and dangerous.

I can't force treatment on a pt. But I am not going to let his refusal put me in a position where I am then expected to do something potentially dangerous to his daughter (move her w/o c-spine stabilizaion).

Have you looked at the data on c-spine immobilization? There's no evidence. Not to mention as her guardian he is legally allowed to select treatment. It is your obligation to provide informed consent. Do you even understand that concept?

The next step isn't abandonment, the next step is getting him on the line with med control and letting him hash it out with a doc.

The doc (or the law) isn't going to side with you.

If I put a fall victim with a significant head injury in my rig without a collar or board and suddenly she can't feel her feet... I don't care what I have the guy sign on scene, its still my name on the pcr and my *** on the line.

Not if you provide informed consent and properly document the refusal.

There can only be 1 person in charge of patient care on your ambulance. If a pt or family member has decided they need to run the show you must be able assert yourself in a professional manor.

What if they're right and you're wrong? What if the family member has considerably more education about the condition. It is astoundingly arrogant to think you can be an expert on everything that comes down the pike. I can assure you if this was the attitude displayed towards me and either of my kids there would be multiple layers of management involved as soon as possible. Those who deserve respect do not need to demand it. I often defer to knowledgeable care givers.

Day to day medical care for a chronic condition and emergency stabilization are two different things. They may be an expert in the condition (or as much of an expert you can be having self-trained via the internet), but EMS professionals are experts in stabilizing patients for transport to hospital. They need to understand that you know what you're doing.

This is insulting. If you haven't been around special needs kids you have no idea the level of education that goes into the parents. Beyond the tenants of airway, oxygenation and supporting circulation there are many times I DON'T know what I'm doing nearly as well as Mom and Dad who have been caring for the kid day in and day out for months and years at a time. These are not "internet experts". These are people who rather often only need a transport provider.

 

[bahnrokt]

It is more dangerous to put her on a back board then leave her off of it. Since when does a head injury mean spinal cord damage? We don't backboard stroke patients....

Oh and the next step would actually be listening to the patient's guardian rather than wasting everyone's time and letting her sit out in the cold. People are allowed to refuse interventions, even if refusing them may be detrimental (in your eyes). Just look at the Jehovah's Witnesses and blood transfusions.

Patient was found unresponsive at the bottom of a tall flight of stairs leading to the ground from a hay loft. Top of stairs is approx 25' from ground. Area where she was found had several large rocks. Father "woke" her and sat her down in a chair 5' away and dialed 911.

You arrive and find the above scene. She is alert but not oriented, slurred speech, right pupil does not react. Large abrasion to left side of head, 2" above ear, moderate bleeding. Several abrasions to elbows, knees, etc consistent with fall from top of stairs. Your partner gets behind her and holds manual.

She is combative with everyone. Does not want to be touched by my crew or family. Keeps repeating that she is tired and wants to nap for the party she is going to later that day and that she only fell from 2 steps up. She can not recount the fall when asked later or remember my partners name which has been told to her several times. I don't recall her vitals other than they were unremarkable.

Are you comfortable transporting her like that?

 

[Aidey]

Yes, perfectly.

 

[Dwindlin]

Are you comfortable transporting her like that?

Absolutely. As others have pointed out, the data on backboards shows is at best of no benefit and at worse causes harm.

 

[JPINFV]

Are you comfortable transporting her like that?

How effective do you think a spine board is (assuming it was effective) against a patient who is fighting it?

 

[CANDawg]

These are people who rather often only need a transport provider.

Well, that and someone who is legally allowed to perform invasive interventions and administer restricted drugs not previously prescribed for the patient by a doctor.

Letting the parent be a major part of patient care and accepting their experience and knowledge is one thing. Giving them carte blanche to your rig and its drug case is another.

As for 'internet trained parents', I admit I was generalizing for dramatic effect. However, to assume that EVERY parent who has a child with a serious chronic medical condition is a de-facto expert on the issue is both unreasonable and unwise.

Yes, some parents may have dedicated a large portion of their lives to understanding the condition, its causes, complications, symptoms and the like. There are also going to be a large portion of parents whose knowledge doesn't stray much past 1) the name of the condition, 2) its impact on the child's day to day life, 3) prescribed medications and doses, and 4) warning signs to watch for. Honestly, I think the smarter decision is to assume the latter situation until proven otherwise.

 

[Tigger]

Well, that and someone who is legally allowed to perform invasive interventions and administer restricted drugs not previously prescribed for the patient by a doctor.

Letting the parent be a major part of patient care and accepting their experience and knowledge is one thing. Giving them carte blanche to your rig and its drug case is another.

As for 'internet trained parents', I admit I was generalizing for dramatic effect. However, to assume that EVERY parent who has a child with a serious chronic medical condition is a de-facto expert on the issue is both unreasonable and unwise.

Yes, some parents may have dedicated a large portion of their lives to understanding the condition, its causes, complications, symptoms and the like. There are also going to be a large portion of parents whose knowledge doesn't stray much past 1) the name of the condition, 2) its impact on the child's day to day life, 3) prescribed medications and doses, and 4) warning signs to watch for. Honestly, I think the smarter decision is to assume the latter situation until proven otherwise.

No one is suggesting that the provider give a treatment because the patient or family asked for it. The provider still gets to choose whether or not to administer something. The patient meanwhile has a right to refuse it, it does not work both ways though.

 

[bahnrokt]

Yes, perfectly.

Absolutely. As others have pointed out, the data on backboards shows is at best of no benefit and at worse causes harm.

How effective do you think a spine board is (assuming it was effective) against a patient who is fighting it?

I'm honestly shocked by these answers. Do your local protocols back you up on this? Mine state a fall or suspected fall of >20' is a major trauma. Major trauma is automatic c spine without overwhelming evidence that MOI could not have effected spine.

 

[CANDawg]

I'm not going to say I didn't contribute, but it is amusing how we went from a conversations about doctors as patients to a conversation about the effectiveness of backboards. :lol:

 

[Aidey]

I'm honestly shocked by these answers. Do your local protocols back you up on this? Mine state a fall or suspected fall of >20' is a major trauma. Major trauma is automatic c spine without overwhelming evidence that MOI could not have effected spine.

You're shocked that protocols aren't 100% up to date and that most protocols aren't based on evidence based practices?