# Patient sign off....then she was dead 6 hours later



## remote_medic (Dec 12, 2008)

Just venting...sharing.

Did a call 2 days ago for a early 20's female having a seizure. Grandmother reports she was "thumping" against the wall. On our arrival she is awake, sleepy but appropriate. Known seizure disorder on Dilantin. She is acting ok but annoyed that we are in her bedroom at 530 am, wants us to leave her alone to sleep. She refuses to go to hospital. Vitals stable, she signs our refusal form. Up walking when we leave

Well, just after noon oclock we are on another call when the call goes out to the address we were at at 530. "female not breathing". Spoke with the crew who responded and they say she had riggor. No resuscitation attempted. Medical examiner case now. Come to find out the girl has a history of drug use and suicide attempts in the past.

While I don't feel responsible, I feel bad. Spoke with my service director and the EMT (many years of experience) on the original call. We all feel the first call was handled appropritely. Just a good reminder why we need to be very thourough with our sign offs. Fortunately we use an electronic run report so I can type as much as I want to in the narrative.

We will see what the report is from the medical examiner.


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## BossyCow (Dec 12, 2008)

I recall a medic digging frantically through the garbage can for a strip he ran on a pt. Was a pickup & dustoff call from a frequent flier who was found dead on the toilet he was helped to the night before by caregivers the morning after... 

"No.. he was fine! I Swear! I have the tape!" 

The tape was found.


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## Ridryder911 (Dec 12, 2008)

Hopefully, your patient report presents that the patient fully understood the risks and not that she was postictal and confused. Also that the Grandmother would assume care of the of the patient. 

R/r 911


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## remote_medic (Dec 12, 2008)

Ridryder911 said:


> Hopefully, your patient report presents that the patient fully understood the risks and not that she was postictal and confused. Also that the Grandmother would assume care of the of the patient.
> 
> R/r 911




Sure did, fortunately I have the habbit of "over doccumenting"...at least that's what my coworkers call it.


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## EMTCop86 (Dec 13, 2008)

remote_medic said:


> Sure did, fortunately I have the habbit of "over doccumenting"...at least that's what my coworkers call it.


 
I am sure your coworkers will be grateful when that "over documenting" saves yours and maybe their butt one day. Rather be safe then sorry.


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## Tincanfireman (Dec 13, 2008)

When I run a medical call at the full-time job (airport), the usual length of any narrative I write will be ~8-10 typewritten lines, be it a skinned knee or cold/flu.  I'll let you figure how long the AMS and MVC narratives can run. I have grown used to the jibes from my "2-3" line co-workers regarding my exhaustive writing, but our legal counsel has mentioned to me that if we ever have to go to court with a case, he hopes it's a call I responded to.  Keep doing what you're doing and remember that ink is cheaper than a good defense lawyer.


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## Onceamedic (Dec 13, 2008)

I'm sorry remote medic.  That can't be an easy situation for you.  In NO way do I think you did something wrong.  The thing I am going to try and take from your experience is the knowledge in my gut that if they call - I am going to haul.  While this policy does not make me popular with my partners (kinda like your "over documentation") one of these days they will be grateful.  At 2:00 am it is pretty tempting to leave them at home with a refusal.  I know that there are cases of "incarceritis" where I have shortchanged the assessment.  This is not what I get paid for.  Thank you for posting about this experience.  It will help anyone that takes a lesson from it.


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## WuLabsWuTecH (Dec 13, 2008)

i've noticed that my run reports get shorter and shorter as time goes on.  When i was fresh out of school, I was writing dissertations, but now some of them are only about a paragraph handwritten.

This is true of the longer shifts as well


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## remote_medic (Dec 13, 2008)

Kaisu said:


> The thing I am going to try and take from your experience is the knowledge in my gut that if they call - I am going to haul.



Maybe I wasn't clear earlier, but the patient refused transport...I didn't refuse to transport her.

I can not take a patient against his/her will. That would be kidnapping.


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## Onceamedic (Dec 13, 2008)

remote_medic said:


> Maybe I wasn't clear earlier, but the patient refused transport...I didn't refuse to transport her.
> 
> I can not take a patient against his/her will. That would be kidnapping.



Yes.. that would be kidnapping.  I'm sorry if I didnt make it clear that I didnt think you did anything wrong.


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## joncrocker (Dec 16, 2008)

Execellent job on reviewing the call. All to many will go around thinking it was their fault or that they could have done more.


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## rhan101277 (Dec 16, 2008)

If they are in a postictal state isn't that considered implied consent?  Granted this women wasn't in such state, but I just wanted to make sure.  Since she would have an altered mental status.


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## sharpenu (Dec 17, 2008)

I am not saying this was what you did, but we all know that there are medics out there that guide patients to refusing care. "You don't really want to go to the hospital for this, do you?"

Medics get in trouble from accepting refusals all the time, but I have never heard of a medic getting in trouble for taking someone to the hospital. 

Postictal patients are considered to be incapable of accepting or refusing care.

Again, I was not on your call so I am not saying that you did anything- I am just throwing out some food for thought.


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## BossyCow (Dec 17, 2008)

rhan101277 said:


> If they are in a postictal state isn't that considered implied consent?  Granted this women wasn't in such state, but I just wanted to make sure.  Since she would have an altered mental status.



I have left many postictal pts at home, but not home alone. For someone with a known seizure disorder, the postictal phase is something common and ordinary. I've stayed on scene long enough for the pt to reach A&Ox3 and then allowed them to sign the refusal.


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## mycrofft (Dec 17, 2008)

*Roger that Bossycow*

The time between event and recovery is part of the eval, since it can reasonably be anticipated that a segment of this population may progress to a life threatening state. Sort of like a diabetic you give sugar to and then they are much better...untyil that sugar spike reverses and powerdives. Sometimes you gotta move slow and think/observe.


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## aussieemt1980 (Dec 26, 2008)

We have a refusal of treatment / transport form that we complete and have a witness or the pt sign, that contains the advice that we gave. We also have one for head injury as well.

By the sounds of it, you did all you could to get the patient off to hospital, but at the end of the day we cannot force the patient. It can be hard, with thoughts that you may not have done enough, but the decision of the patient is final.

Don't tear yourself up over it. We lose too many medics who burnout over the matters of consent and the consequences of the patients decision and it would be a big issue in the US as it is here.

I had a patient once who came off a motorbike and had another one ride over his lower back. We responded, transported to a clearing post (motorsport event), and arranged for transport for possible internal injuries. Before transport arrived, the patient declined transport. As part of my advice, I told the patient to attend the local ED if he is not feeling well over the next 48 hours, and I found out a week later from the pts father that he decided to attend the local ED and was admitted to the nephrology unit due to kidney injury (he was urinating blood).

The father thanked me for recommending the hospital, as what was back pain and external bruising resulted in his son being put on standby for emergency surgery.

I always cover myself by recommended attendance at the local GP or hospital if the symptoms do not subside or get worse. (Remember the panadol commercial - if pain persists see your doctor?)


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## remote_medic (Jan 2, 2009)

A follow up for anyone who cares...

Cause of death was ruled suicide by intentional overdose of multiple perscription and non perscription drugs.


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## RESQ_5_1 (Jan 7, 2009)

I recently had to go to court for a pt that was charged with DUI of cocaine. As a result of my well written PCR, I was able to accurately detail what I found, how I found it, and everything pertinent to the call. I don't think there could be such thing as over-documentation.


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## crotchitymedic1986 (Jan 12, 2009)

This is why i am against leaving patients at home, until the day we have the ability to do labs and xray.  Which isnt to say you did anything wrong, but there is just no way to rule out every possible diagnosis with the limited tools we have.  

Think about it this way:  A 14 year old girl comes to the ER for dyspnea, after breaking up with her boyfriend.  She is obvioulsy hypeventilating, and everyone knows it, and treats her accordingly.  But they will not discharge her until they do a blood gas to confirm hyperventilation.  If the ER doc will not discharge her without supporting lab work, I do not understand why we feel so comfortable to not transport this same patient to the ER.


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## BossyCow (Jan 12, 2009)

crotchitymedic1986 said:


> This is why i am against leaving patients at home, until the day we have the ability to do labs and xray.  Which isnt to say you did anything wrong, but there is just no way to rule out every possible diagnosis with the limited tools we have.
> 
> Think about it this way:  A 14 year old girl comes to the ER for dyspnea, after breaking up with her boyfriend.  She is obvioulsy hypeventilating, and everyone knows it, and treats her accordingly.  But they will not discharge her until they do a blood gas to confirm hyperventilation.  If the ER doc will not discharge her without supporting lab work, I do not understand why we feel so comfortable to not transport this same patient to the ER.



Wow, so all your patients have good insurance eh? I am not going to transport a stable pt with no significant mechanism of injury and no obvious signs of symptoms of disease unless they insist on it. For example, wife calls 911, says husband quit breathing, we show up, husband is awake, conscious and talking to us. Says he suffers from sleep apnea and fell asleep in a chair, he swears  he's fine and wife over-reacted. Skin color is good, all vitals WNL, EKG shows NSR, O2 sat in high 90's am I going to make this guy go to the hospital and spend the next several hours being told that he's okay after every test in the book? No, we're going to chuckle over his wife's nervousness, shrug off his apologies and tell him its all in a days work and we're going to have him sign a release, document the heck out of it and tell him to call us if he needs us again anytime.

Sending this pt to the ER just to cover my posterior is a waste of the ERs time, the pts money and the taxpayers dimes.


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## reaper (Jan 12, 2009)

crotchitymedic1986 said:


> This is why i am against leaving patients at home, until the day we have the ability to do labs and xray.  Which isnt to say you did anything wrong, but there is just no way to rule out every possible diagnosis with the limited tools we have.
> 
> Think about it this way:  A 14 year old girl comes to the ER for dyspnea, after breaking up with her boyfriend.  She is obvioulsy hypeventilating, and everyone knows it, and treats her accordingly.  But they will not discharge her until they do a blood gas to confirm hyperventilation.  If the ER doc will not discharge her without supporting lab work, I do not understand why we feel so comfortable to not transport this same patient to the ER.




The difference is she was an adult, who was competent to make her own medical decisions. She signed a refusal and did not want to be transported. See, in this country we do not kidnap adults that do not want treatment!


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## crotchitymedic1986 (Jan 12, 2009)

And in this country we have lazy medics who do not always transport patients that they should.  We also have ignorant medics who fail to do any training other than the minimum, and therefore make poor patient care decisions that result in patient death (see washington DC EMS).

And age has nothing to do with it, most ER docs will do an ABG on any hyperventilating patient, regardless of age.


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## Tincanfireman (Jan 12, 2009)

BossyCow said:


> I am not going to transport a stable pt with no significant mechanism of injury and no obvious signs of symptoms of disease unless they insist on it. For example, wife calls 911, says husband quit breathing, we show up, husband is awake, conscious and talking to us. Says he suffers from sleep apnea and fell asleep in a chair, he swears he's fine and wife over-reacted. Skin color is good, all vitals WNL, EKG shows NSR, O2 sat in high 90's am I going to make this guy go to the hospital and spend the next several hours being told that he's okay after every test in the book? No, we're going to chuckle over his wife's nervousness, shrug off his apologies and tell him its all in a days work and we're going to have him sign a release, document the heck out of it and tell him to call us if he needs us again anytime.


 
I agree with Bossy; an analogous situation in the fire service is the home smoke alarm going off at three in the a.m. We respond, check the house, pull the nearly-dead battery out of the beeping detector to silence the low-battery alarm, tell the homeowner to get a new one in the morning, and to call us back if they have any further problems. What we don't do is pull all the sheetrock off the studs, kill power to the building, run LEL's in every room, and, finding nothing, tell them to get a new battery in the morning. Serving the public good means taking our experience, training, judgement, and knowledge into account when making a decision, and acting accordingly. If we ran every runny nose to the ER to rule out pneumonia, there wouldn't be any units left for those who need us, and the ER would need to have a waiting room the size of their parking garage.


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## remote_medic (Jan 12, 2009)

crotchitymedic1986 said:


> And in this country we have lazy medics who do not always transport patients that they should.  We also have ignorant medics who fail to do any training other than the minimum, and therefore make poor patient care decisions that result in patient death (see washington DC EMS).
> 
> And age has nothing to do with it, most ER docs will do an ABG on any hyperventilating patient, regardless of age.



Again it all comes back to consent. I just don't think you get it. It is not our job to "scare" or "influence" or "convince" patients to accept care that they do not want to recieve. We can simply teach and allow people to make their own decisions.

I'm sure you understand the concept of kidnapping or battery. By pressuring a patient to do something they do not want to do you are walking a fine line. By threatening a patient with a line like "if you don't come to the hospital you can die" you risk being accused of forcing care/transport onto someone. I don't know about you but I've seen several patients with a valid DNR/DNI at the end of their life end up on a vent because a doctor said "if I don't put this breathing tube in you will die" and the patient says or nods ok and spends their last 4 days on life support. Again, the patient consented but did they fully understand what they were consenting to? The issue is all about consent and respecting the choice of the patient.

I realize these are 2 different scenerios, but the general issue remains the same. An adult can make a choice, good or bad, right or wrong, or for life or death.

Like I have said earlier in this topic. I feel bad this young woman died but I do not feel responsible for her death. If this same call occured tomorrow, I would handle it the same.


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## BossyCow (Jan 12, 2009)

crotchitymedic1986 said:


> And in this country we have lazy medics who do not always transport patients that they should.  We also have ignorant medics who fail to do any training other than the minimum, and therefore make poor patient care decisions that result in patient death (see washington DC EMS).
> 
> And age has nothing to do with it, most ER docs will do an ABG on any hyperventilating patient, regardless of age.



Wow.. your name is really apropos isn't it? So, because there are some EMS workers out there who falsify reports, minimize their training, don't transport pts that need to go in, and the repeated examples you post in this and other threads is Washington DC EMS, we are all supposed to read these posts on how rotten everyone is that make it seem that overkill in every area is required to make up for the incompentence of a few? If you have issues with your agency, keep them specific to your agency. Not all agencies are as lax.


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## crotchitymedic1986 (Jan 12, 2009)

I understand completely.  But very few patients actually refuse AMA.  Most are talked out of going by EMS.  You should not kidnap any patient, but at the same time, you should not talk them out of going, because you want to get back to the station, or because you could be sleeping, or because the hospital they go to is too far away.  You said the key words, which is that you have a duty to educate the patient to the risk of not being transported.  If they refuse AMA, so be it.

And as good as you are, you are limited by the technology (or lackthereof that you have).  

A perfect example from my pediatric hospital ER days.  An infant comes in for drooling.  The patient has been seen by EMS twice, and not transported, and has been to the ER and the doctor's office for followup, and given the diagnosis of "teething".  An xray is performed, and it is negative.  Doctor opts to scope the patient, and guess what, a cellophane wrapper from a cigarette pack is found just above his vocal cords (cellophane doesnt show up on xray).

And lets take it one step further.  Lets assume that 99.9 % of the time, your agency gets it right.  Now multiply your refusal percentage x .01%.  Whatever that number is, is that an acceptable death rate for your department ?

You run 60,000 calls with 20,000 "refusals".  That could be up to 200 deaths per year if you are right 99.9% of the time.


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## remote_medic (Jan 12, 2009)

crotchitymedic1986 said:


> And lets take it one step further.  Lets assume that 99.9 % of the time, your agency gets it right.  Now multiply your refusal percentage x .01%.  Whatever that number is, is that an acceptable death rate for your department ?
> 
> You run 60,000 calls with 20,000 "refusals".  That could be up to 200 deaths per year if you are right 99.9% of the time.




Actually, it would be 20 people...


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## crotchitymedic1986 (Jan 12, 2009)

my bad, my fingers are too fat for this laptop, 20 is correct.  But is that acceptable ?  How many 911 agencies are in your state ?  If they all only have 0.01% death rate, how many patients is that ?  Multiply all EMS calls nationwide by that statistic, is that acceptable ?


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## rescuepoppy (Jan 12, 2009)

.  

"A perfect example from my pediatric hospital ER days.  An infant comes in for drooling.  The patient has been seen by EMS twice, and not transported, and has been to the ER and the doctor's office for followup, and given the diagnosis of "teething".  An xray is performed, and it is negative.  Doctor opts to scope the patient, and guess what, a cellophane wrapper from a cigarette pack is found just above his vocal cords (cellophane doesnt show up on xray) "

 Since we don't carry a scope or x-ray around with us this is why I and the majority of medics I have worked with try to get patients to go to the hospital when we have questions. This is not laziness as I have spent lots of time and energy trying to talk patients into transport on more than one occasion. But after you have done all you can and the patient still refuses you have no recourse other than to comply with their wishes.


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## remote_medic (Jan 12, 2009)

crotchitymedic1986 said:


> my bad, my fingers are too fat for this laptop, 20 is correct.  But is that acceptable ?  How many 911 agencies are in your state ?  If they all only have 0.01% death rate, how many patients is that ?  Multiply all EMS calls nationwide by that statistic, is that acceptable ?




Yes, that seems like an incredibly successful rate. I obviously don't know exactly what I'm talking about here (and I suspect the same from you) however 20 deaths among 20,000 sign offs seems like a very good number. 

Anyone else have an opinion?


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## crotchitymedic1986 (Jan 12, 2009)

It would be a good number if we knew for a fact that it was only 0.01%.  Since we do not report these failures to a central agency, we only know about the cases that make it to the headlines.  For all we know the percentage maybe 1, 2, 5, or 10%.  

But I would suggest that 1 preventable death is 1 too many.


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## jrm818 (Jan 12, 2009)

Well that makes one of you.  When speaking system-wide resource and funding restrictions come into play.  If I told you you could save one life every year if every ambulance had two attending physicians who transported every patient and ran every test in the book, would it be worth it?  Heck NO!

This represents a troubling trend in medicine to me.  The nervous nelly school of medicine abandons good clinical judgment in favor of myopic focus on more tests to rule out any chance of a mistake or hidden super-rare-only-seen-once-ever illness, without concern for the wide ranging implications of unnecissary medicine .  Unnecessary testing and treatment comes at a real cost to the patient - financially, emotionally, and physically - and can't be justified by your stastical sophistry.  Even if 0.1% of refusal patients died, in order to even start to suggest that EMS should not be taking refusals you have to also show that

1. the hospital could have diagnosed the disorder at the time of their being seen by EMS
2. the hospital would have run the necessary test(s) or performed the proper exams
3. the condition would have been treated successfully by the hospital following proper diagnosis, AND the patient would have a positive outcome.

good luck with that.  For example - this refusal is part of the 0.1%.  That said, transport for a seizure would have resulted in the hospital saying "you had a siezure" and discharging the patient with a one page description of "adult seizures."  Said patient would then return home, and proceed to kill themselves anyways.

Of course you ignore the implications of this unnecessary examination in a hospital to the other 99.9% of patients who would otherwise refuse.  Whats the infection rate for hospitalized patients?  Of 100 patients you transport who weren't sick, a couple of those people just got an infection they wouldn't otherwise have.  2 or so probably went into bankruptcy (leading to stress, bad eating and exercise habits, and a heart attack for 0.2 of them probably) because of unexpected bills.  1 died in an ambulance crash en route.  Another couldn't afford his brake job and died in an unrelated automobile crash due to failed brakes...which is a ridiculous example, but no more ridiculous than proposing we throw out clinical judgment making and treat everyone as if they have some undiagnosable zebra of a fatal illness.  

Sorry, sometimes people die, and sometimes medical personnel make mistakes.  Yes, you want to always strive to be better, but more medicine is not always better (quite the contrary).

Selective C-spine clearance is a good example of when less is better (and the nexus rules are based on in hospital ct criteria...the same sort of idea).  Unfortunately the paralyzing fear of a lawsuit has pushed medicine in what I think is the wrong direction.  Thankfully there is now a push to get away from so-called "defensive medicine."

"The delivery of good medical care is to do as much nothing as possible"


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## triemal04 (Jan 12, 2009)

What he said.  Pretty well put.

It would be nice if everybody who calls 911 only called when they had an actual medical problem that required an ambulance (or even a medical problem period), but that is not the case.  People call us, and sometimes we really aren't needed.  When that is the case, I don't understand how anyone can be a proponent of taking someone to the hospital when you KNOW that they do not need it.  Wouldn't it be better to explain to them what is going on, their options, and that an ambulance transport, while available, is not neccasary?

As far as talking pt's out of going by ambulance...yeah, I do that.  When appropriate.  And I don't document that they refused AMA, since they didn't.  What's the problem with that?  Someone with a cut to a finger that will require a couple of stitches does not need an ambulance, especially when they are quite capable of getting to the hospital (or clinic, or urgent care, or MD's office) by other means.  I'm sure that you, crotchy, would just take them in by ambulace, allowing your employer to send out another large bill, but personally, I'd rather discuss with the pt what their options are for getting treatement, and then let them pick the option that worked best for them and was appropriate.


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## IaEMT (Feb 9, 2009)

"I am not going to transport a stable pt with no significant mechanism of injury and no obvious signs of symptoms of disease unless they insist on it. For example, wife calls 911, says husband quit breathing, we show up, husband is awake, conscious and talking to us. Says he suffers from sleep apnea and fell asleep in a chair, he swears he's fine and wife over-reacted. Skin color is good, all vitals WNL, EKG shows NSR, O2 sat in high 90's am I going to make this guy go to the hospital and spend the next several hours being told that he's okay after every test in the book? "

I had to reply to this one, cuz it rang a bell with me.  We had a call a while ago, wife called in, said her husband was unresponsive, about 0100.  We get there, guy is awake, A&Ox3, NSR, 98% SpO2 on room air.  States he feels fine, no cardiac history whatsoever, but bed is soaking wet where was laying and he was NOT incontinent.  We hook him up, BP is 118/68, NSR.  Guy says he feels fine, then tells us, "oh ya, and I passed out day before last for no reason, weird huh?".  My partner and look at eachother and convince him to go in (in our bus) and get checked out.  He jokes with us the whole way in, we are hospital based so we hang around.  Run full chest panel/12 lead, the whole works.  Everything comes back with normal ranges other than a slightly elevated WBC, but they are gonna keep him overnight for obs.

We go back to quarters, and 10 mins after get there we are paged to the floor for a code.  It's OUR patient!  He'd gotten to his room, nurse was attaching telemetry, and he without warning goes into full arrest.  Of course, this was observed arrest, in house, and we worked on him for over an hour (our doc would NOT give up).  End result...he died.  Later find out he was 100% blocked on the right  and 90% blocked on the left and the labs showed none of this.  Something broke loose, and it killed him DRT.  Just goes to show, you never know, ever.  You do the best you can, you trust your training, and you have to try NOT to back and second guess everything you did.   But that's near impossible, now, isn't it?


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## Aidey (Feb 10, 2009)

Has anyone considered that maybe she ODd AFTER the EMS crew left? I've had a few patients who have taken ODs that resulted in seizures, and none of them came out of being postictal/unresponsive. Maybe this girl was upset that she had another seizure and decided enough was enough. 

Yes, there are medics and EMTs who talk patients out of going to the hospital. It probably shouldn't happen as often as it does, but it does happen. However, there is nothing so far that I've read here that indicates that is what happened, so lets cut remote_medic a little slack here.


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