Disagreeing with a EMT-P

[beachemt]

SO i was working with a paramedic the other night and i love working with htis guy, he is a wealth of knowledge. we had a situation though ias a basic disagreed with the course of action but we let it run obviously the way he wanted. heres the scene.

dispatched to a 91yof injury from a fall. 0130 am
we arrive on scene and find the pt laying semi supine but legs pulled toward the chest behind the door.
Problem #1 I can see the pt and she has obviously fallen, but its almost impossible to grab c-spine and open the door to gain access to the pt.
So i let the paramedic take over and he was able to move the pt safely, so problem solved. once we got in and started to assess the pt couldnt tell us how she got there didnt remember loc and wasnt verbally responsive dont get confused she just wasnt talking much. She had bruising allover and some on her cheeks and the pt's family didnt know how long she had been there but that she had gone to bed at 6 pm.
was the pt AOx3? well she followed commands could say her name and knew her her family was so you tell me. but she was slow to respond not very communicative

she was apparently fine no dcapbtls no md hx glucose was 117.

I wanted to take her in to just get checked out by the ER because again she was not sure how she got behind the door but could follow simple commands

the paramedic decidced was fine leaving her home. Like i said i like this guy and know hes a very smart emt-P but it just sat with me since it happened like two weeks ago.
what do you guys think you would have done ?

 

[rmellish]

You're missing one crucial point of information. Did she want to go to the hospital?

 

[MedicPrincess]

Some additional information...

The patient was 91. The family was on scene. Did they confirm she was responding normally for her?

Was this her normal mental status? At 91, she may not have a lot to say, may not "feel like" talking, or may not be able to say very much.

You mention no medical history...At 91 it is very unusal not to have anything. What medicines was she taking?

Were the bruises old bruises or new bruiese? Old people can be covered in black and blue.

Was she complaining of anything hurting?

 

[JPINFV]

You're missing one crucial point of information. Did she want to go to the hospital?

This.

The patient was 91. The family was on scene. Did they confirm she was responding normally for her?

You mention no medical history...At 91 it is very unusal not to have anything. What medicines was she taking?

and these.

Additionally, did the family seem like they were taking an active interest in the well being of the patient?

Now, yes, the book/class answer is "Zomg, LOC/can't remember the event, board, collar, high flow O2, yadda, yadda, yadda." Welcome to the real world, though. The problem with scenarios like this, though, is that there are a lot of subtle non-verbal communication cues as well as cues from the family that will be the difference between transport and no transport. This is also where medical history comes into play (dementia, Alzheimer's, etc). If the family could be relied on to monitor the patient and call if anything changed, I don't necessarily see where the problem with leaving the patient at home would be.

 

[beachemt]

well as for wanting to go to the hospital she wouldnt really respond when we asked her. her family said she really wasnt on any medications and we ran through a list but nothing really even high blood presure or anything. the bruises were both old and new the one on the cheek though the family said they hadnt seen before.

so i guess im getting the consensus that he made the right choice and even after a year of emt im still thinking to much by the book haha

 

[reaper]

Did he assess the Pt? BGL,12 lead,stroke assessment? There is a reason she can not remember how she fell.

If all checks out OK, pt does not want to be transported and family will remain with pt, then leave her at home. Elderly Pt's are not dumb. Most realize that if they go to the hospital, they may never get out. Take a lot of time talking with the pt, this will help you asses their neuro. If you feel confident that they are fine, then help them to their bed and let them rest. Instruct family to keep an eye on pt and call 911 if any thing changes.

 

[emtlady76877]

If she had of been in the floor over night there would have been signs of that would have told you so.

 

[BossyCow]

At 91, with some pre-existing dementia, a trip to the ER is often more traumatic than the results of the fall. Had the medic seen her before? Was he familar with what 'her normal' was?

An MPD explained it to me this way early in my EMS experience... "She's either okay and she can stay home, or she's not. If she's not, she's going to get worse and you can bring her in then." We have to consider the full effects of that ambulance trip to an ER on someone who really needs the consistancy of her home routine.

 

[mikie]

Did he assess the Pt? BGL,12 lead,stroke assessment? There is a reason she can not remember how she fell.

Would that be warranted (an honest question)?

 

[Ridryder911]

Would that be warranted (an honest question)?

Yes, can you rule out AMI for etiology of fall? The same reason one does a FSBS.

Personally, it sounds like the Paramedic did the right thing. Leaving the patient in responsible hands and if need be having the family call 911 PRN. As described, she did not talk much, it appears many times either the patient is HOH or possibly has senile dementia. Various degrees of bruising indicates that she has history of multiple falls or even blood clotting disorder, again not an emergency but needs to be assessed.

Now, one has to think..."What would the ED do?"... Really, if she is not hurting, where does one go? Labs, U/A, possible a CT scan for what? Not to be crude, but alike what was described she is 91. Doubtful, that any major intervention is to going to occur acutely. Again, emphasis placed upon f/u with her PCP at a later date.

R/r 911

 

[IrishEMT]

She had bruising allover and some on her cheeks and the pt's family didnt know how long she had been there but that she had gone to bed at 6 pm.

Sketchy. If she wasn't on warfarin or coumadin, I'd be suspicious. Old people bruise easily, but facial bruising is weird. Any idea if it was from the event? Also, why did her family have no idea how long she was on the floor?

Yeah, I'm kind of overly-vigilant about elder abuse, too. I ALWAYS suspect it.

 

[traumaangel26]

If you have a question about why the paramedic did this ASK? They will either explain why so you can learn or not tell you cause they are full of themselves. Most medics will explain a course of action if you ask. There is only one stupid question. The one you don't ask!!!!:mellow:

 

[Jersey]

Bottom line, never disagree with the Paramagicians, they have an omnipotent fount of knowledge.

 

[tydek07]

Hmmm...

It is hard to give you the answer, as there is a lot of the assessment and findings missing. Right off the bat, I am going to advice you to talk to the paramedic you were with. That way you will get the answer from him and the reasons he decided to not transport her.

I am sure he had good reason to leave her there and feel comfortable with it. She is older, does she have dementia? Has he been called there before for the same situation? Did he decide pt was A&O x3, and therefor he could really not "make" her go? Was family able to look after her throughout the night? and we can go on and on and on........

So, the only way you are going to get the answer you are looking for is by asking the paramedic you were with.

Also, I would be concerned about the bruises on the face. Were they caused by the fall? Or should someone be concerned about abuse?

 

[BLSBoy]

Bottom line, never disagree with the Paramagicians, they have an omnipotent fount of knowledge.

Challenge flag on the field.

Just because we go to school longer, and have more knowledge does not equal instant, and infalliable superiority.

I learn from basics who have been in the field longer, and shorter then I have.

Don't be an *** about questioning a medic, but don't hesitate to ask questions.

Respectful manner and tone, followed by saying something like, I am just trying to learn some more go a long, long way.

 

[Clibby]

Please don't take this the wrong way guys and gals.

What I have found interesting in my relatively short experience is that nurses tend not to have as many inhibitions when disagreeing with a doctor, and the doctor usually takes it well. He knows he can miss something and/or the nurse knows the patient better. The nurse may have taken a CEU on something relevant, or noticed something the doctor didn't. Usually the doctors have explanations for their action and explain it to the nurses. Sometimes its vice versa, especially with experienced nurses. In the end someone learns something new be it the nurse or the doctor. Both are concerned with the patient and so inevitably the patient wins.

EMTs however have this fear of asking questions when they may have the right answer. Anybody can miss things and sometimes we don't always make the right call. It is true that the patient is in the care of the highest provider and that provider usually has reasons for their actions. Just ask. Be curious. You cannot learn if you don't ask, and higher providers cannot learn if they aren't open to new ideas and new ways of viewing situations. The best way to stay on your game is through experience and teaching it to others.

When there is a disagreement, paramedics have reasons for their actions and EMTs have reasons for disagreeing. Both sides need to be open to that and sort it out. Most of times the paramedic is going to be right, but there will be that once in a blue moon where the EMT knew something different due to his own experiences/education. When someone is wrong, teach them. When your wrong (both parties) be open to learning something new. Just remember to be respectful to each other.

There are good doctors, nurses, paramedics, and EMTs, and there are bad ones. Remember that and don't judge someone based solely on what cert they have. We all have worked with fantastic paramedics and awful ones; and we have all worked with fantastic basics and incompetent ones. The ratios may be different, but both exist at every level.

 

[BossyCow]

It all has to do with your self confidence. I know that not having all the answers on every call doesn't make me a bad EMT. It makes me human. I personally prefer to be told that I was wrong so next time I can do better than to attempt to impress everyone with how much I know.

So, I will risk my pride to gain knowledge. Those who cannot are merely too defensive or too invested in appearing knowledable to work on becoming knowledable.

 

[natrab]

I think it's fine to ask questions after the call, but during the call you should be there to support the medic when you're in a 1 and 1 situation.

The situation described is more of a legality/liability question depending on where you're at. Where I work, our medicine, unfortunately, is governed by legalities and potential for lawsuit, so our policy basically states the we drag all old people to the hospital simply because of the co-morbid factor of being old. Of course, we don't all do that, and I often contact the hospital to get permission to leave people (especially those with dementia etc.) at home when they seem ok. However we are never allowed to advise someone not to go to the hospital where I work.

Damn lawyers....

 

[Jeffrey_169]

Its a judgement call really

I am not going to say who's school of thought was right or wrong (I don't know for I wasn't there), but I will say that you are the pts advocate, and you must do that you think is the right thing to do at that moment. Don't ever take the opinion of someone else as the undesputed truth if your gut tells you somethng is wrong with this picture, and just because someone has a differing opinion, and they have more education, doesn't mean that they aren't making a mistake or having an off day. We are all human, and we all make mistakes. I am NOT saying argue on scene with a superior, but if you have a valid objection or disagreement, then don't be affraid to voice it at the appropriate time and place.