Paramedic Incompetence Question

[Handsome Robb]

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?

Because there is not cut and dry answer. You said it yourself in the part that I bolded above. Spinal motion restriction by mechanism alone has no evidence to support it, you have to look at the whole picture. I posted my protocol for you to see, it leaves the mechanism up to our interpretation as providers.

Like someone else said, I'm paid to recognize indications for a treatment and trust myself to recognize those indications. I'm a young provider at 22 but I haven't heard any complaints about my decisions in my treatment paths. Constructive criticism is a different story, but I welcome it.

 

[medic417]

W/o getting drawn into the great amount of bs this topic has generated I will only state once Paramedic arrives they are in charge if they decide they want to be. Just like when you arrive at the hospital, doctor can ignore you and just take over patient.

[YOUTUBE]http://www.youtube.com/watch?v=WJ_yQ02xwsM[/YOUTUBE]

[YOUTUBE]http://www.youtube.com/watch?v=Otm4RusESNU&feature=endscreen&NR=1[/YOUTUBE]

 

[mrswicknick]

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?

Position found in, MOI (I would not consider 3-4 feet as significant), any presentation of abnormalities in the spinal exam, obvious deformity, reported pain, and pain response in the lower and upper extremities.

Now, if someone flew 200 ft on a motorcycle and didnt report any pain in the neck, he's still getting a board. Every situation is different, but its always a matter of using all the tools in your toolbox and making the decision you feel most comfortable with.

 

[mrswicknick]

Because there is not cut and dry answer. You said it yourself in the part that I bolded above. Spinal motion restriction by mechanism alone has no evidence to support it, you have to look at the whole picture. I posted my protocol for you to see, it leaves the mechanism up to our interpretation as providers.

Like someone else said, I'm paid to recognize indications for a treatment and trust myself to recognize those indications. I'm a young provider at 22 but I haven't heard any complaints about my decisions in my treatment paths. Constructive criticism is a different story, but I welcome it.

^^^^ This is exactly what I have been trying to say this whole time. My apologies if it got strewn into much other B/S. I have always been terrible at explaining things over forums, and sorry to anyone that took offense.

 

[AMF]

Because there is not cut and dry answer. You said it yourself in the part that I bolded above. Spinal motion restriction by mechanism alone has no evidence to support it, you have to look at the whole picture. I posted my protocol for you to see, it leaves the mechanism up to our interpretation as providers.

Like someone else said, I'm paid to recognize indications for a treatment and trust myself to recognize those indications. I'm a young provider at 22 but I haven't heard any complaints about my decisions in my treatment paths. Constructive criticism is a different story, but I welcome it.

So, I guess what I'm getting at is would you not board a patient unless they had unequal pupils? Had unilateral weakness? Complained of back pain? Only one of these things is obtainable in unconscious patients. I'm in EMS because I want to be able to take a good history, so I'm uncomfortable when the patient can't talk. When I'm uncomfortable, I tend to take precautions. Sure, that's my training, but it's also my intuition as a human being. But, by all means, please enlighten me. Where do you draw the line?

 

[Handsome Robb]

So, I guess what I'm getting at is would you not board a patient unless they had unequal pupils? Had unilateral weakness? Complained of back pain? Only one of these things is obtainable in unconscious patients. I'm in EMS because I want to be able to take a good history, so I'm uncomfortable when the patient can't talk. When I'm uncomfortable, I tend to take precautions. Sure, that's my training, but it's also my intuition as a human being. But, by all means, please enlighten me. Where do you draw the line?

I never said that. Don't try to be cute, please. You're being defensive. You called out a provider with more education and probably experience than yourself and we answered the call.

Just because the patient is unconscious doesn't mean you can't get information about the events prior to your arrival from a bystander. If they fell far enough, crashed their car hard enough, got hit with something hard enough to knock themselves out and remain that way when I arrive or caused other significant injuries they are getting a board unless they are awake, I deem the competent and they refuse and in that case they are signing a refusal of SMR. Ever heard of kinematics of trauma?

Like I said before, there is no cut and dry line so stop asking me to draw one, please.

 

[AMF]

Position found in, MOI (I would not consider 3-4 feet as significant), any presentation of abnormalities in the spinal exam, obvious deformity, reported pain, and pain response in the lower and upper extremities.

Now, if someone flew 200 ft on a motorcycle and didnt report any pain in the neck, he's still getting a board. Every situation is different, but its always a matter of using all the tools in your toolbox and making the decision you feel most comfortable with.

Position found in indicated head trauma. We'll move past the moi. Spinal exam is unobtainable due the pt's mental status. I probably would have done a physical, had I been the primary, but other then the lac/cont, I didn't see any obvious deformity. Reported pain is obviously something I can't assess. Pain response is nil in the extremities. Hence, my unease.

 

[AMF]

I never said that. Don't try to be cute, please. You're being defensive. You called out a provider with more education and probably experience than yourself and we answered the call.

Just because the patient is unconscious doesn't mean you can't get information about the events prior to your arrival from a bystander. If they fell far enough, crashed their car hard enough, got hit with something hard enough to knock themselves out and remain that way when I arrive or caused other significant injuries they are getting a board unless they are awake, I deem the competent and they refuse and in that case they are signing a refusal of SMR. Ever heard of kinematics of trauma?

Like I said before, there is no cut and dry line so stop asking me to draw one, please.

I'm not sure what you "never said," but I'm not being defensive. I'm honestly curious. Wouldn't you be? Someone pointed out that there were clinical signs that I could have looked at, which confused me, so I asked. I'm not sure why you think I didn't get a history from the bystanders, since that's where all this head trauma stuff came from. But really, I'm looking for clinical signs that definitely indicate or contraindicate boarding that can be observed in the pseudocomatose patient.
Edit: Ahh, I see what you think I thought you said. No, signs like unequal pupils are just something I would look for to indicated neurological trauma. I'm not saying that you said that. But are they wrong?

 

[Handsome Robb]

I'm not sure what you "never said," but I'm not being defensive. I'm honestly curious. Wouldn't you be? Someone pointed out that there were clinical signs that I could have looked at, which confused me, so I asked. I'm not sure why you think I didn't get a history from the bystanders, since that's where all this head trauma stuff came from. But really, I'm looking for clinical signs that definitely indicate or contraindicate boarding that can be observed in the pseudocomatose patient.
Edit: Ahh, I see what you think I thought you said. No, signs like unequal pupils are just something I would look for to indicated neurological trauma. I'm not saying that you said that. But are they wrong?

No worries and no you aren't wrong. Per your protocols SMR of this patient would have been indicated. Per my protocols it is indicated as well however we have some space for interpretation. Would I board this patient? Probably. Would I be happy about it? Not really. The point I have been trying to make is that mechanism alone is not a good indication of SMR.

 

[rescue1]

So, I guess what I'm getting at is would you not board a patient unless they had unequal pupils? Had unilateral weakness? Complained of back pain? Only one of these things is obtainable in unconscious patients. I'm in EMS because I want to be able to take a good history, so I'm uncomfortable when the patient can't talk. When I'm uncomfortable, I tend to take precautions. Sure, that's my training, but it's also my intuition as a human being. But, by all means, please enlighten me. Where do you draw the line?

It's a terrible answer for you but...it does kinda depend. Looking at where I'm lying right now (in my bed about 3 feet off the ground), I can safely say that if I fell off my bed I would almost certainly not require spinal immobilization. If I were 95 with a history of previous Fxs and osteoporosis, or if I'm in a bunk 6--7ft off the ground then it's a whole different ball game. It appears the pt did not dangle his head off the side of the bed and fell three feet directly on top of his skull, but more crashed off the bed and happened to take some of the fall on his face/forehead.
Correct me if I'm wrong about what happened, of course

To put significant MOI in perspective, I jumped off a galloping horse last month (don't ever do that, trust me). It was going around 30mph and I guess I was around 5 feet off the ground. I ended up breaking my leg when I landed (on my side) and I promise you I hit the ground with a hell of a lot more force then your pt did. I had no neck or back pain at all. Hell, I didn't even bruise...minus my fractured fibula.

The sad thing is that spinal immobilization is CYA for 99% of pt's we do it to. I've gotten my board back before I've cleared the hospital many times, since the nurses will remove it after asking "do you have back pain?" and getting a no response from the pt.

That being said, if your paramedic's reason for not boarding him was that he wanted to walk him out instead of carry him, he does not fall into the "making good clinical decisions for the patient" category.

Just use some clinical judgement and don't blindly follow protocol...technically your pt (with GCS 9) is a category B trauma patient per my state's protocol, and you should request a medivac helicopter to transport your patient to the nearest Level 1 trauma center, with no need to consult beforehand with the trauma center and obtain permission. Don't be that guy.

 

[AMF]

It's a terrible answer for you but...it does kinda depend. Looking at where I'm lying right now (in my bed about 3 feet off the ground), I can safely say that if I fell off my bed I would almost certainly not require spinal immobilization. If I were 95 with a history of previous Fxs and osteoporosis, or if I'm in a bunk 6--7ft off the ground then it's a whole different ball game. It appears the pt did not dangle his head off the side of the bed and fell three feet directly on top of his skull, but more crashed off the bed and happened to take some of the fall on his face/forehead.
Correct me if I'm wrong about what happened, of course

To put significant MOI in perspective, I jumped off a galloping horse last month (don't ever do that, trust me). It was going around 30mph and I guess I was around 5 feet off the ground. I ended up breaking my leg when I landed (on my side) and I promise you I hit the ground with a hell of a lot more force then your pt did. I had no neck or back pain at all. Hell, I didn't even bruise...minus my fractured fibula.

The sad thing is that spinal immobilization is CYA for 99% of pt's we do it to. I've gotten my board back before I've cleared the hospital many times, since the nurses will remove it after asking "do you have back pain?" and getting a no response from the pt.

That being said, if your paramedic's reason for not boarding him was that he wanted to walk him out instead of carry him, he does not fall into the "making good clinical decisions for the patient" category.

Just use some clinical judgement and don't blindly follow protocol...technically your pt (with GCS 9) is a category B trauma patient per my state's protocol, and you should request a medivac helicopter to transport your patient to the nearest Level 1 trauma center, with no need to consult beforehand with the trauma center and obtain permission. Don't be that guy.

Haha I did that when I was a kid. My back was sore for a good week, though.

Yeah, I recognize that it's just the way I've been taught. "You>Your partner>Your patient."

 

[Aidey]

That being said, if your paramedic's reason for not boarding him was that he wanted to walk him out instead of carry him, he does not fall into the "making good clinical decisions for the patient" category.

I kind of wonder if it was more "If you want to do this unnecessary intervention fine, but I'm not helping you with it".

 

[Fish]

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.

Scenario:
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) to try to wake him before we got there. Bystanders report that the patient was found in the "kowtow" position by his bed, 3' to 4' feet off the ground. Patient presents with a laceration on his forehead several cm in diameter. He is A&Ox0 with a GCS of 9 (5 Motor, barely; 2 Vocal, barely; 2 Pupilary, but fighting it) and has bilateral but slow reaction of pupils to light.
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.

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

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.

They do not out rank you if they are not in your service/department, however. It is not "your patient until you transfer care" It is their patient when they arrive on scene seeing as they are a higher Medical Authority. That being said, no Medic in his/her right mind should ever blow off another Medical providers suggestion with a "sure, whatever"

 

[rescue1]

It's all good...my EMT refresher class still teaches me to give 15lpm of O2 to all patients because it "can't hurt". I can't wait for that to get taken out of the protocol.

All of this being said...if you ever have to make the decision before your transport arrives and you feel better if you board the patient...do it. It's your patient, you're there and we're not, and you're never going to get in trouble for following protocol. Just remember that when it comes to treatment, more is not always better. Every trauma patient doesn't need a backboard, high flow oxygen and a lights and sirens ALS transport.

 

[rescue1]

I kind of wonder if it was more "If you want to do this unnecessary intervention fine, but I'm not helping you with it".

That's still kind of a **** move. If you think something is medically unnecessary, as the highest provider on scene you should be explaining why you don't want it performed. It's not like you're free of liability if that treatment goes wrong...you were the paramedic, pt care was your responsibility.

 

[Fish]

That's still kind of a **** move. If you think something is medically unnecessary, as the highest provider on scene you should be explaining why you don't want it performed. It's not like you're free of liability if that treatment goes wrong...you were the paramedic, pt care was your responsibility.

I'll agree with that, It is my Patient as the Medic. If the BLS FF on scene says oi, I wanna backboard a particular patient that I do not feels needs it I am not going to say sure, if you want to. It is a yes, or a No. And if it is a no it is a respectful no, more of a "Eh, I don't really think we he/she needs that" and if they take issue with it they can express why, incase there was something I was missing here. And if I still feel like it is a no, then it is a no and I will tell them I will call them after the call to explain why.

 

[Aidey]

That's still kind of a **** move. If you think something is medically unnecessary, as the highest provider on scene you should be explaining why you don't want it performed. It's not like you're free of liability if that treatment goes wrong...you were the paramedic, pt care was your responsibility.

Sure it is a **** move, but sometimes it can be easier to look like a lazy **** than be an argumentative ****.

 

[rescue1]

Eh, true. Still doesn't make it right, though.

 

[Handsome Robb]

Sure it is a **** move, but sometimes it can be easier to look like a lazy **** than be an argumentative ****.

Does letting the FD carry many of our patients down stairs and what not make me fall into that category? By all means I have no problem doing it myself but if they're all over it I'm not going to ruin their fun.

Edited for stupid iPhone autocorrect.

 

[Tigger]

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.

It is the EMS provider's job to weight the pros and cons of spinal immobilization, like any procedure or intervention, before performing it.[/I]

Do you see these statements as a bit contradictory?

Exhaustive protocols and restrictive standing orders have eliminated a great deal of decision making for field providers in some places, but you still need the knowledge to decide when to implement an intervention or follow a protocol. That sort of thinking is the most important part. Just because a treatment or intervention is not contraindicated does not make it indicated. While it is reasonably likely that boarding this patient will ddoue little further harm, doing something only to follow protocol or cover your bum is a poor clinical decision. If you cannot medically justify something, don't do it.

I think that many in EMS are unnecessarily afraid of losing their license to practice. It is more likely that one loses their license for doing something that they should not have than failing to do something. When it comes to SMR this becomes even more true given that their is some evidence that it doesn't improve any outcomes.