Paramedic Incompetence Question

[rescue1]

My main concern with boarding the pt, besides the minor MOI and the fact I hate boarding people, is the fact that as a very drunk individual, the pt is almost guaranteed to vomit during transport, and you have to be very quick to roll the board and suction when they do. If the medic rides by himself in the back (which I assume he does), and he's trying to start an IV when this happens, he has to move, roll the board, hold the board on the side, get the suction and suction all by himself very quickly.
I had a paramedic on a call once who wanted to board an intox with no significant MOI (slid down into the grass) because it "would be easy to roll them if they threw up".
It didn't work out so well...it's a good thing we both rode in the back, cause he was a big dude to roll and we had to do it several times. Puked all over me and the medic. I was not a happy man.

 

[STXmedic]

A patient with a very significant MOI with a severe head injury is very likely to vomit, too (let's say motorcycle accident with no helmet). Would you not board this patient? Just saying, there's plenty of reasons to not board somebody. Vomitus should not be your primary reason.

 

[AMF]

Any fall on planet earth for a 102 kg object is about 1000N. I think the kinetic injury and the resulting forces on the vertebrae at impact might be more relevant here.

[Not to mention, did his entire body weight impact at the same time, or was perhaps half his body mass supported by the bed, while his head struck the ground?]



As I said earlier, I'd probably board this patient too if there's no history. I wouldn't trust that the laceration on his head didn't happen from being struck with a bat. I don't trust people in general.

However, if there's clear and reliable evidence that he rolled out of bed, it's hard to see a positive mechanism, even given a very generous interpretation of what constitutes a mechanism.

There's two different arguments at play here:

(1) The argument that it's best for your continuing financial security to remain employed and follow the medical control guidelines in any unclear situation to prevent loss of income / job security.

AND

(2) That it's better you do what's in the best medical interest of the patient.

I don't think anyone is telling you to go out and get fired. They're simply point out that a lot of the patients we immobilise probably shouldn't be immobilising in the first place, that there's almost no evidence behind this practice, and there is proof of potential harm. That simple.

I'll agree to that.

To reiterate what everyone else has said, the glaring problem here is that you are treating the pt as a checklist, rather than looking at the over-arching clinical picture. My biggest problem with this if that you are calling this pt critical, when he clearly is not.

You have trauma secondary to a fall, of low mechanism, with ETOH consumption. You are treating the numbers, not the pt. Yes, your pt has a GCS lower than 15, but can you think of a reason? Look at the situation, the pt is obviously so intoxicated that he urinated all over the floor. Now, assuming you have drank a beer or two before, if you were drunk enough to do that, do you think you would be absolutely alert? No.

Yes, he has a depressed RR, but is he cyanotic? Cool to the touch? His pupils are sluggish... but why? Again, think about what is causing this. Does a 4 foot drop really sound like something that could cause someone to start circling the drain? Or, could it possibly be the fact that he has again, obviously is incredibly intoxicated and all of these are rxns to depressants like ETOH. Also, why in the hell would you put an OPA in a pt who is vomiting? Vomit in an OPA would cause one hell of a blocked airway, and maybe even cause aspiration. And if you are getting full motor function, I would be you his gag reflex is still in tact, and that he is going to vomit the second you try to get it in, and you will have a true airway problem. Why wouldn't you just suction?

The patient was not vomitting. The patient did not have full motor function. The patient did not have a gag reflex. I'm not sure you read the first post correctly.

How about this, what can a medic do for this pt to help him? Per your protocols this is indicated:

Intermediate/Critical Care/Paramedic
7. IV en route
8. If shock present, perform fluid challenge to maintain BP > 90 mmHg
9. Cardiac Monitor
10. Manage airway as needed. See 'Blue 3 and 5.'

Was the pt in shock? If not, then #8 is out of the question. Again, manage the airway, but do you think his airway is compromised due to trauma, or due to the ETOH. Again, look at the clinical picture.

Its a matter of looking at the clinical picture, and having some situational awareness. Where I practice, if I called for ALS in this situation not only would my Medics not transport this pt after an evaluation, but they would chew me out post call for not doing exactly what I just mentioned and taking them away from a pt that truly needs their help. Do you really think its a good Idea to take a medic unit OOS just to transport some joe that drank too much?

Dont take this as me bashing you. Just as you were, I was in the same situation not too long ago and followed the book to the dot until I was fortunate enough to sit down with our Senior Medics and even our med director to shed some light on what a true critical pt is. I would advise you try and do the same. I hope rather than looking at this as an attack you will see at as another way to think of the practice of care, and begin to further yourself as an EMT.

Again, I think you misunderstand. We're QRS, which means we don't transport. Are you saying that the patient didn't need transportation?

 

[AMF]

That's odd. I work as an intermediate and have standing orders for meds...

The fact of the matter here is you don't have to be "taught to think", it should be a spontaneous action. Especially if we want to further this job into a profession.

I mean't without OLMC, in the state of Maine.
Intermediates vary quite a bit from state to state.

 

[mrswicknick]

Your missing the point. Are you saying he had no gag reflex because you physically checked, or because you are assuming by the numbers. He is intoxicated, which is why those numbers are the way they are.Looking at the situation and the surroundings you can tell he has had plenty of booze, and seeing as you dont transport I could understand you not recognizing this, but I promise you that pt, especially in the state that he is, may not be presently vomiting, but absolutely will the second the amb he is transported in starts moving. I would not stick a OPA in his mouth, both because I promise you he does have a gag, and because at his level, he absolutely will vomit, and that will cause an obstruction.

Absolutely he needs to be transported. But he does not need a medic unit. Can you not dispatch a BLS rig for transport?

 

[mrswicknick]

I think overall you are still not getting the point. Treat the pt, not the numbers. Look at the clinical picture. Your pt is not a flow chart.

 

[systemet]

I think it's fairer to say that there's a much greater risk he'll vomit after being moved around, placed supine and is subject to longitudinal acceleration and deceleration forces. I wouldn't say it's necessarily guaranteed.

From an airway management perspective, I can say it's much easier to justify intubating someone because of a failure to oxygenate or ventilate, or wishing to avoid gastric insulfation with PPV, than because of a vague aspiration risk. Especially if the patient is immobilised, and therefore a greater risk for being a difficult intubation.

I would not stick a OPA in his mouth, both because I promise you he does have a gag, and because at his level, he absolutely will vomit, and that will cause an obstruction.

I think this rests on why we place an OPA. We're not placing it because there's an altered level of consciousness, nor because the gag reflex is absent (which it is a fair minority of the population at large. Insert crude reference here). We're placing it when we need to maintain a patent airway, because we're concerned that the tongue is going to occlude the pharynx.

If the patient's breathing, not snoring, and well oxygenated, the OPA isn't indicated if you're giving 1 on 1 care and reassessing them.

Absolutely he needs to be transported. But he does not need a medic unit. Can you not dispatch a BLS rig for transport?

I think this depends a little on system resources, and the history available. I mean, yes, he's probably just drunk. The trauma is probably superficial. There's unlikely to be anything to do for him beyond making sure his airway doesn't evaporate and that he doesn't aspirate while his alcohol dehydrogenase turns all his blood alcohol to vinegar.

But if he's really a GCS of 9, and there's ALS available, they'll be better equipped to manage his airway if his condition deteriorates, and there remains a possibility that there are cointoxicants on board or the alcohol intoxication is masking a serious pathology.

I just want to point out that I'm not trying to defend or attack anyone here. A lot of people much smarter than me have commented on this thread and given some extremely intelligent input. I'm just giving my opinion of what I would do / be concerned about as an ALS provider.

 

[rescue1]

A patient with a very significant MOI with a severe head injury is very likely to vomit, too (let's say motorcycle accident with no helmet). Would you not board this patient? Just saying, there's plenty of reasons to not board somebody. Vomitus should not be your primary reason.

Of course I would...thats a significant MOI for spinal injury. Being drunk and falling down a couple feet is not. Drunk people fall down all the time without paralyzing themselves. If he'd been sober it's likely he would have either a) used a band aid or b) had someone drive him to the ER.
You and I both know when that patient got to the ER, he'd be off the board as soon as the doctor said "does your neck/back hurt?" anyway.

Now if the pt had fallen out of a bunk bed, or had unequal pupils, or had some other indication that there was significant trauma, he'd get a board, projectile vomiting or not.

 

[mrswicknick]

Sysetmec, I agree with everything you said, and most of what you are saying I was implying. Its hard sometimes to express what you are thinking in full detail with stuff you assume is already being thought of in the back of your head if that makes any sense. Also, the reason I wouldnt take the time with an ALS rig is I see no immediate life threats, and in my area of practice it would take just as much time to get this pt to the hospital than to wait for an ALS rig to arrive and transport. If I thought airway patency was a true issue on this pt however, I would absolutely snag an ALS rig. Hope that clarifies.

 

[AMF]

Your missing the point. Are you saying he had no gag reflex because you physically checked, or because you are assuming by the numbers. He is intoxicated, which is why those numbers are the way they are.Looking at the situation and the surroundings you can tell he has had plenty of booze, and seeing as you dont transport I could understand you not recognizing this, but I promise you that pt, especially in the state that he is, may not be presently vomiting, but absolutely will the second the amb he is transported in starts moving. I would not stick a OPA in his mouth, both because I promise you he does have a gag, and because at his level, he absolutely will vomit, and that will cause an obstruction.

Absolutely he needs to be transported. But he does not need a medic unit. Can you not dispatch a BLS rig for transport?

I don't dispatch anyone. The company I get dispatched with rides P/P, P/I, and occasionally P/B. I've never seen a non-paramedic-unit truck, though I know they're common in parts of the country that can't afford paramedics.

Of course I would...thats a significant MOI for spinal injury. Being drunk and falling down a couple feet is not. Drunk people fall down all the time without paralyzing themselves. If he'd been sober it's likely he would have either a) used a band aid or b) had someone drive him to the ER.
You and I both know when that patient got to the ER, he'd be off the board as soon as the doctor said "does your neck/back hurt?" anyway.

Now if the pt had fallen out of a bunk bed, or had unequal pupils, or had some other indication that there was significant trauma, he'd get a board, projectile vomiting or not.

Drunk people fall down all the time without paralyzing themselves, yes. They also fall down and, on occasion, suffer serious neurological damage. It is the EMS provider's job to weight the pros and cons of spinal immobilization, like any procedure or intervention, before performing it. Yet the paramedic did not say to me, "It is my professional opinion that boarding this patient would do more harm than good." He said, "feel free to board him, but I would suggest against it, not for the patient's well-being, but because I'd rather not carry him down the stairs." And I can empathize with him. I didn't want to carry him down the stairs either, gut my primary's intuition was that a) it would not do more harm then good, and that b) it would allow us to cya. So I guess the question no one wants to answer is, where would you draw the line as to a moi significant enough to want to board? I know it has to do with a number of clinical signs, as well, but would you, as a basic, or even a paramedic, trust yourself to recognize them?

Also, the patient had no gag reflex. Yes, I checked.

 

[mrswicknick]

You dont have to be snippy. You didnt say that you checked for a gag, therefor I assumed. Also, just because we staff BLS only units doesnt mean we cant afford them, we just hold incredibly high standards for our medics, and there is only one program you can go through to become one in our city. (King County Medic One) We, as basics, are trained to recognize the true need for ALS, and dispatch as necessary. It makes sure we have the highest trained medics, and not just any person that went through the community college class and passed their NREMT-P. To any medics that have done that route, I am not saying that you have any less training, but I am sure we all know many people, both BLS and ALS, that shouldn't be practicing emergency medicine.

And yes, I am paid to trust myself to recognize those clinical signs. That is what my training did for me, and why I strive to learn more any chance I get.

 

[NomadicMedic]

Also, just because we staff BLS only units doesnt mean we cant afford them, we just hold incredibly high standards for our medics, and there is only one program you can go through to become one in our city. (King County Medic One) We, as basics, are trained to recognize the true need for ALS, and dispatch as necessary. It makes sure we have the highest trained medics, and not just any person that went through the community college class and passed their NREMT-P. To any medics that have done that route, I am not saying that you have any less training, but I am sure we all know many people, both BLS and ALS, that shouldn't be practicing emergency medicine.

hahahah. As soon as I saw this, I blew soda out of my nose. You're either a stretcher fetcher with AMR or TriMed and if you're like most of the warm bodies that fill those seats, you're in no position to get snippy over ANYTHING.

 

[mrswicknick]

Like I said, I know a lot of people that shouldn't be doing this job. A lot. Im also a premed student, and have devoted my life to learning about medicine. So no, I am not like my peers.

 

[mrswicknick]

Also, I am not trying to be snippy. In no way am I interested in having a pissing contest over the internet, I am simply trying to put out another perspective. In the whole, it seems like he is treating the numbers, not the pt and the clinical picture, and I felt that adding some perspective, from a EMT-B point of view, might help.

 

[NomadicMedic]

A premed student. Hmm. Good for you.

The ridiculous "We only call ALS for PTs that need it" quote that is perpetrated by King County Fire and the Private Ambulance companies is a crock. The firefighters are scared to make almost any decision because they're afraid of getting yelled at by a medic who was called out of his recliner. (See: Skyway) And the private ambulance companies are scared to death that someone will say something to a fire fighter or medic and make them look bad. (Try making a PT care suggestion to a KCMO medic and see how long you're employed.)

It's simple. This PT may not need a board, but a PT that is so intoxicated that he can't communicate or effectively protect his own airway is most likely going to need a tube. (The OP did say he didn't have a gag, right?) And that is a clear indication for an ALS response.

And by the way, I take great offense at the statement, “... we have the highest trained medics, and not just any person that went through the community college class and passed their NREMT-P.” I've met some pretty lame KCMO medics that I wouldn't let work on my dog.

Just sayin'.

 

[mrswicknick]

And by the way, I take great offense at the statement, “... we have the highest trained medics, and not just any person that went through the community college class and passed their NREMT-P.” I've met some pretty lame KCMO medics that I wouldn't let work on my dog.

Just sayin'.

I have also met many of them that I would trust with my life, and I know many, many others from other areas with different training (see TCC) that I wouldnt let touch me. Maybe I have too much faith in Copass' students, but I find many of them to be some of the best.

I have never once been afraid of getting yelled at by a medic because, at least to this point, I have never called them when I havent needed them, or when I have. Yes, if this pt is having problems keeping his airway patent, I would absolutely have an ALS eval, as I have said before, but from what I am reading I dont think that was the case.

 

[JPINFV]

Like I said, I know a lot of people that shouldn't be doing this job. A lot. Im also a premed student, and have devoted my life to learning about medicine. So no, I am not like my peers.

Your peers as in young adults, your peers as in college students, or your peers as in pre-meds?


/[insert comment about how anyone can be pre-med]

 

[NomadicMedic]

You're right. Not the place for this argument. Sorry for the thread hijack.

 

[mrswicknick]

Your peers as in young adults, your peers as in college students, or your peers as in pre-meds?


/[insert comment about how anyone can be pre-med]

My peers as in the warm bodies ls7 was explaining. I understand anyone can be premed, but it was in reference to the aforementioned warm bodies and how many of them have absolutely no interest in medicine and very little understanding further than the class they took to become a basic.

Why must everything on this forum turn into a personal pissing match? I am only trying to give my perspective, and never did I imply that I was superior to anyone, yet most responses to mine seem to be, rather than educational, a put down.

 

[AMF]

You dont have to be snippy. You didnt say that you checked for a gag, therefor I assumed. Also, just because we staff BLS only units doesnt mean we cant afford them, we just hold incredibly high standards for our medics, and there is only one program you can go through to become one in our city. (King County Medic One) We, as basics, are trained to recognize the true need for ALS, and dispatch as necessary. It makes sure we have the highest trained medics, and not just any person that went through the community college class and passed their NREMT-P. To any medics that have done that route, I am not saying that you have any less training, but I am sure we all know many people, both BLS and ALS, that shouldn't be practicing emergency medicine.

And yes, I am paid to trust myself to recognize those clinical signs. That is what my training did for me, and why I strive to learn more any chance I get.

You assumed that I assumed. I understand that you don't think highly of your fellow EMTs, but try not to assume the worst.

And I'm not being snippy here, I promise: What are those clinical signs? Ignore the fall-- what about the patient's presentation would indicate the need for full spinal immobilization?