# forced catheterization



## cbmedic (Sep 20, 2012)

Two nights ago, a drunk/intoxicated patient was brought into the ER. He was violent, and security put him into four point restraints. His clothes were cut off. I was one of the attending RN's, and I was ordered to catheterize him. I refused. I said I would not cath him unless he was sedated, to spare him any pain or humiliation. I was told that the MD would not introduce any drugs into his system until urinalysis results came in. 

What would you have done in this situation?


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## Veneficus (Sep 20, 2012)

cbmedic said:


> Two nights ago, a drunk/intoxicated patient was brought into the ER. He was violent, and security put him into four point restraints. His clothes were cut off. I was one of the attending RN's, and I was ordered to catheterize him. I refused. I said I would not cath him unless he was sedated, to spare him any pain or humiliation. I was told that the MD would not introduce any drugs into his system until urinalysis results came in.
> 
> What would you have done in this situation?



Cath him. That's what we always do.

We don't drug suspected tox patients until the urine sample. 

If you make his tox screen positive, you mask organic evidence of altered mental status.


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## VFlutter (Sep 20, 2012)

I would absolutely cath him. And honestly I have had a Foley before and they are not that bad, uncomfortable but not really painful. Would it be less "embarrassing" for him to urinate all over himself and cause potential skin breakdown? 

When do we ever sedate or provide analgesia for Foley catheters? Have you ever done one? Its clean, lubricate, insert. That is it. I put multiple caths in a shift on patients who are completely A&O, non sedated, non pain meds on board, etc and I have never felt like it was even remotely needed. He is already intoxicated what more do you want?


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## Shishkabob (Sep 20, 2012)

Cathed.  The medical benefit outweighs the temporary pain.  Do you sedate people before an IV?  I don't.



Having said that, I've made it quite known that I will not go down without fighting when someone tries to cath me while conscious.  That's for exit only as far as I'm concerned!


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## NYMedic828 (Sep 20, 2012)

ChaseZ33 said:


> I would absolutely cath him. And honestly I have had a Foley before and they are not that bad, uncomfortable but not really painful. Would it be less "embarrassing" for him to urinate all over himself and cause potential skin breakdown?
> 
> When do we ever sedate or provide analgesia for Foley catheters? Its clean, lubricate, insert. That is it. I put multiple caths in a day on patients who are completely A&O, non sedated, non pain meds on board, etc and I have never felt like it was even remotely needed. He is already intoxicated what more do you want?



Having had one for surgery before, the worst part is when they take it out...

Felt like I had to urinate 24/7 for 2 days.


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## Aidey (Sep 20, 2012)

Don't most hospitals also have lidocaine lube for foley insertions?


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## Shishkabob (Sep 20, 2012)

NYMedic828 said:


> Felt like I had to urinate 24/7 for 2 days.



So... 24/2?  :lol:


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## Veneficus (Sep 20, 2012)

Aidey said:


> Don't most hospitals also have lidocaine lube for foley insertions?



If that is what comes in the kit.

I never read the package before. Reading the fine print after setting up a sterile field and gloving up was never on my "to do" list.


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## firetender (Sep 20, 2012)

*Just wondering...*

I can't imagine you having gone through RN training and not seeing that catheterization is relatively harmless and painless to the patient. No more so than an IV, though I definitely have the same personal opinion as linuss!

I'm wondering if you thought the order for catheterization was to punish the pt.

I'm wondering how your refusal to follow up on a Drs. orders turned out for you.

I'm wondering if you felt you could get an adequate urine sample from a combative patient in restraints. Did you thing you could?

Guess I'm just a wondering idiot!


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## bigbaldguy (Sep 20, 2012)

cbmedic,
I definitely see where you're coming from on this. The first time I saw a forced catheterization it was on a disabled teenage girl from a group home and it was very traumatic for both the young girl and the people who took part in it. It really shook me up and I'm pretty sure I felt very much as you do now. In my situation I feel they definitely could have taken a few moments to try and calm the young woman down before strapping her down and doing it. All that said it is necessary that they obtain a clean urine sample often for the benefit of the patient. If they were to sedate the patient it could as mentioned mask the presence of another medication. Like you I wouldn't want to be the person to do it but if you keep in mind it is for the benefit of the patient it might make it a little easier to stomach. Sometimes in a bad situation the best we can do is mitigate the crapiness surrounding the situation. I always think of it this way. If I don't do it the next person who gets tasked with it may have even less care/respect for the patient than I do. So unless it's something that that I think is absolutely abhorrent I just do it and try to make it as pleasant as possible for the patient. Remember that unpleasant can be a very relative term in some situations.

Often in cases of suspected DUI/DWI they need to do the tox screen for purposes of a criminal investigation as well. Here in Houston they generally do a blood draw rather than a urine screen for suspected intoxication.

edit : I know someone who once had to help get a blood sample and urine sample from a young woman who had been sexually assaulted after being drugged. She was also very altered/combative and had to be restrained :/ The explanation they received was that the half life in some drugs used in sexual assaults are so short that even a minimal delay can be the difference between proving a person was drugged or not drugged. I was told something similar by a SANE nurse once as well. Not applicable in this situation but something to keep in mind in situations like this.


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## VFlutter (Sep 20, 2012)

Aidey said:


> Don't most hospitals also have lidocaine lube for foley insertions?



I will take a look next time I am at work but as far as I know it is just regular lube without lidocaine.

Sometimes we try to use condom catheters as an alternative but they just do not work as well and usually come right off if they patient is combative


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## bigbaldguy (Sep 20, 2012)

ChaseZ33 said:


> I will take a look next time I am at work but as far as I know it is just regular lube without lidocaine.
> 
> Sometimes we try to use condom catheters as an alternative but they just do not work as well and usually come right off if they patient is combative



The ones I've seen do not have lidocaine in them.


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## Aidey (Sep 20, 2012)

Maybe it is one of those things that is an option if it is felt it is needed. I know I've heard it mentioned by the ED nurses.


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## cbmedic (Sep 20, 2012)

firetender said:


> I can't imagine you having gone through RN training and not seeing that catheterization is relatively harmless and painless to the patient. No more so than an IV, though I definitely have the same personal opinion as linuss!
> 
> I'm wondering if you thought the order for catheterization was to punish the pt.
> 
> ...







1: Catheterization is relatively harmless and painless to the patient.... UNLESS it is forced upon the patient blatantly and flagrantly against his will as he screams and writhes.

2. Yes, in fact, I did feel it was somewhat punitive.

3. I do not yet know what my refusal will entail. But I will stand by my decision.

4. I am an advocate for patients' rights.

5. "Guess I'm just a wondering idiot!"   I couldn't have said it better.


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## NYMedic828 (Sep 20, 2012)

Linuss said:


> So... 24/2?  :lol:



-_-


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## Veneficus (Sep 20, 2012)

cbmedic said:


> 3. I do not yet know what my refusal will entail. But I will stand by my decision.



Can't speak for where you work, but all the places I have been, we would just sigh and ask somebody other than the new guy to do it.

I have put in more than my fair share of "combat catheters" and it seems to me the "pain and suffering" is mostly psychological. 

I have actually written recently about punitive action, we will see if it gets published.

However, it may be the attitude portrayed that makes it seem "punitive."

From the medical standpoint, the patient is altered and does not have decision making capability. Urine tox must be determined in order to best serve the patient.

I would say the patient is just going about things the hard way.


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## Handsome Robb (Sep 20, 2012)

Cath him.

His decision to get loaded on whatever he was on, now he has to face the music. If you're blasted to the point that you end up in the hospital you don't have much dignity left to lose. Call me an :censored::censored::censored::censored::censored::censored::censored: but it's true. 

Like others have said it's now a diagnostic issue and they're going to need a sample for UA and a catheter is the easiest way to do that. Unless you want to volunteer to stand in the room with a cup and try to catch the sample....have fun with that


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## Veneficus (Sep 20, 2012)

NVRob said:


> Unless you want to volunteer to stand in the room with a cup and try to catch the sample....have fun with that



Vene's rule of EMS #1.

"Never wrestle with a man holding a lightsaber."


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## Medic Tim (Sep 20, 2012)

cbmedic said:


> Two nights ago, a drunk/intoxicated patient was brought into the ER. He was violent, and security put him into four point restraints. His clothes were cut off. I was one of the attending RN's, and I was ordered to catheterize him. I refused. I said I would not cath him unless he was sedated, to spare him any pain or humiliation. I was told that the MD would not introduce any drugs into his system until urinalysis results came in.
> 
> What would you have done in this situation?





cbmedic said:


> 1: Catheterization is relatively harmless and painless to the patient.... UNLESS it is forced upon the patient blatantly and flagrantly against his will as he screams and writhes.
> 
> 2. Yes, in fact, I did feel it was somewhat punitive.
> 
> ...



I love when people come here asking what if questions and then when others question them they get pissy.

What the MD ordered was standard for this type of pt. Refusing only "prolonged the pt's pain and humiliation" as you say. The reason why sedation and other drugs are not given has already been explained.

Why do you feel it was a punishment?
Was this the first time you have encountered this kind of situation? if not how was it handled differently?
How would you have handled it knowing that drugs would affect the lab results?


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## Handsome Robb (Sep 20, 2012)

Veneficus said:


> Vene's rule of EMS #1.
> 
> "Never wrestle with a man holding a lightsaber."



Win. :lol:


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## Aidey (Sep 20, 2012)

So the patient was violent enough he was placed in 4 point restraints, and his clothes were cut off, rather than removed with security assistance. Why do you think he would have been anything other than combative when the foley was placed? 

Why do you feel it was punitive? Because he as combative? Do you believe he would have been any less combative if you attempted to have him urinate in a cup or urinal? Do you believe it would have been any less "humiliating" for him to urinate on himself? How did the catheter violate the patient's rights? Do you understand that being a patient advocate does not always mean doing what is warm and fuzzy for the patient?

Edit: If it patient was brought in because of intoxication, why do you think adding to his intoxication is beneficial? A foley takes a couple of minutes, sedating him could mean he spends another couple of hours in the ED.


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## usalsfyre (Sep 20, 2012)

Veneficus said:


> Vene's rule of EMS #1.
> 
> "Never wrestle with a man holding a lightsaber."









May the Schwartz be with you....


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## Medic Tim (Sep 20, 2012)

I see your Schwartz is as big as mine


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## VFlutter (Sep 20, 2012)

cbmedic said:


> 1: Catheterization is relatively harmless and painless to the patient.... UNLESS it is forced upon the patient blatantly and flagrantly against his will as he screams and writhes.
> 
> 2. Yes, in fact, I did feel it was somewhat punitive.
> 
> ...



Was this a straight cath or foley? It is not punitive if it is a standard of medical care for that situation. A catheter is an appropriate procedure for this situation.

Not to sounds arrogant but do you really know what it means to be a patient advocate? What patient rights are you trying to protect? I hear this thrown around a lot by people and it typically comes down to "The patient should be able to do whatever they want". If that is the case then you should have left him to die drowning on his own vomit on the side of the road. 

So if this patient was intoxicated and driving and killed a school bus full of children then got brought into the ER, would he have the right to refuse an IV blood draw because it was painful and humiliating? 

Or another situation: A patient came into the ER with a shattered pelvis after an MVA in a wheelchair van. He was writhing in pain and kept saying "Dont touch me, let me die, kill me now, it hurts too much" Should we have just stopped and let him die? should we have not taken any images because we would have caused pain by manipulating his body? Should we have just loaded him up on narcotics even if he was peri-arrest and unstable? Or better yet should we have gotten a Psych consult for his suicidal comments?


You opened up Pandora's box....


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## bigbaldguy (Sep 20, 2012)

I happen to like warm and fuzzy folks. 

Now lets turn it down a notch, my warm and fuzzy goes only so far. 

A question was asked, either answer it politely or move on. 

I'm now watching this thread when I have much better things to do so be nice.


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## VFlutter (Sep 20, 2012)

bigbaldguy said:


> I happen to like warm and fuzzy folks.



We will have to agree to disagree with that one :blink:


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## Veneficus (Sep 20, 2012)

ChaseZ33 said:


> What patient rights are you trying to protect?



I think when people are new, the only thing they can base patient advocacy on is what they would want done to themselves or a close relation.

That is slightly out ofcontext though. 

They see the "brutality" of the the action without understanding the intent. 

Let's take a look at it from a different perspective.

This patient was intoxicated. But the mechanism that alters the mental staus is inconsequential. It could just as easily have been an accidental poisoning, hypoglycemia, etc. 

If you were having chest pain, you would likely want to go to the hospital, be evaluated with EKGs, labs, maybe even an angio CT. You want and need to know what it going on. (The reason that physicians focus so heavily on diagnosis is that one you decide on something, because of understanding on why that causes pathology, the treatment is intuitive.) But in order to get these diagnostics, it is not without a marginal amount of suffering. You may even require diagnostic vascular surgery. (I can assure you as a coping mechanism when it comes to dignity, when you are on that table, you are a slab of meat. Even your head is obscured removing your humanity.) 

But the average patient thinks nothing of the associated loss of dignity with bypass surgery.

But take this in the context of your brain. When your brain is messed up, it has its own set of symptoms. If you want help with your heart or liver when it was messed up, why would you not want help with your brain when it is messed up?

In order to do that a set of diagnostics has to determine if there are "forces" outside of the brain (like toxins, renal failure, etc.) or "forces" inside the brain, (vascualture, neurons, neoplasms, etc.) which are causing this alteration in personality. 

So in the event you or a close relation winds up in the hospital and the organ involved is the brain, wouldyou really want less diagnostics? No diagnostics? Would you want at least the sandard of care if not the all that could be done in order to discover and relieve (I didn't use the word "heal" on purpose)  your sickness?

To not only retain the vegatative aspects of the brain, but also the parts responsible for who "you" are?

Making sure the patient gets the best diagnostics and treatment when they cannot communicate or even control themselves is patient advocacy.

The only thing that makes it different from an unconscious person is they still have muscle activation. (which does complicate the matter slightly.) 

Not wanting to be in the patient's position yourself is not advocacy. It is your desire for you.


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## luke_31 (Sep 20, 2012)

It wasn't a forced catherization at all. It is a standard treatment for an altered patient to get a urine toxic screen if the cause is unclear.  Granted the patient might not have known that if he got blitzed that he was going to get a foley.  But look at it this way, what if he has gotten this intoxicated before and has been through the same situation and knew what happens to him when he shows up in the hospital like this.  In this case you can assume that he gave his consent as he knew exactly what his consequences were going to be getting this intoxicated.


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## abckidsmom (Sep 20, 2012)

Beyond all this, when the standard of care dictates that you need a clean urine sample, you catheterize the patient, come what may.  I am still a little scarred for life by the straight cath episode of my 2.5 yo daughter who spiked a temp up to 106.7 on a Wednesday afternoon. 

We needed to know, immediately, what her big deal was, and getting a urine sample from a 2 year old happens with 4 big grown ups holding her screaming, writhing self down, and slipping in the straight cath.  Later, the LP.  

It sucks.  And yet...we just do it, because it's the right thing to do.

I will venture that perhaps the issue you have with the situation is this perceived injustice on top of disrespectful behavior from the staff.  THAT is the part where you can be an advocate, and do what you can to make them stop teasing the caged bear, but good luck with that as the new nurse, who is also a medic.

Those are NOT the kind that have an easy first year.  Ask me how I know.


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## bigbaldguy (Sep 20, 2012)

abckidsmom said:


> It sucks.  And yet...we just do it, because it's the right thing to do.
> 
> I will venture that perhaps the issue you have with the situation is this perceived injustice on top of disrespectful behavior from the staff.



Well said.


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## mycrofft (Sep 21, 2012)

*stray shots*

Suprapubic needle urine collection? Need a screen or a blindfold. Or a couple hits of nitrous.(Kidding about the nitrous).

If an IV is an inevitability, get a serum sample? Might reveal an organic reason as well.

"Don't medicate them they'll be stuck in the ER longer"....very ethical.

Remember the urine results will be inadmissible for LE if the pt is resistive even if he/she is ALOC (altered level of consciousness). So test results will need to be released to LE only in a sealed envelope for their medical people to read.

Sometimes if you don't have the training and experience you have to fall back on the closest info you have. OP, I support your actions as being the best you had, and wish you luck integrating this into your learning curve.


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## DrParasite (Sep 23, 2012)

cbmedic said:


> I said I would not cath him unless he was sedated, to spare him any pain or humiliation.


I believe the "forced" part is the fact that the combative patient didn't to be cathed, and the "patient advocate" part was because he wasn't medicated or sedated for a potentially painful procedure.  at least that's how i'm interpreting the OP's post. 

Either way, there are sometimes procedures that get done that aren't the most pleasant, but are medically necessary, and need to be done despite the altered person not wanting it.


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## Aidey (Sep 23, 2012)

mycrofft said:


> "Don't medicate them they'll be stuck in the ER longer"....very ethical.



Sedating a patient for a procedure that normally does not require sedation for the comfort of the RN treating the patient isn't ethical either.


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## Survivor2222 (Jul 10, 2018)

I know this is an old thread but I found it pretty interesting. 

I was a pre med student who became an EMT briefly and decided to become a trauma therapist instead. 

My question: 

Why are patients allowed to have DNRs and able to refuse life saving care in some circumstances, but not forced medical procedures like a forced cath? 

You may know what is best for the patient, but when does patient consent matter? When do patients have choice? Is it when you deem themableto make those decisions? 

I have worked with more than one client who has ptsd symptoms from forced medical care they didn’t want, and others who had pre-existing PTSD thy was significantly worsened. The numbers are not huge, but they are significant. Some are so traumatized or retraumatized they refuse routine medical care and treatment. 

So how is traumatizing the patient with your good intentions good for health if ignoring consent means they later endanger their lives with suicide attempts and refusal to get even the most routine care? 

I get that there are timwspatients can’t think for themselves. Right now there are a number of lawsuits against law enforcement for forced catherizations on resistant patients, even times it was done in the name of health and not legal proceedings. 

Consent needs to matter more in healthcare.


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## VFlutter (Jul 10, 2018)

Survivor2222 said:


> Why are patients allowed to have DNRs and able to refuse life saving care in some circumstances, but not forced medical procedures like a forced cath?



Patients, whom are deemed competent to make decisions, are able to refuse any medical procedure or treatment. Do not think that was ever being argued.



Survivor2222 said:


> You may know what is best for the patient, but when does patient consent matter? When do patients have choice? Is it when you deem themableto make those decisions?



See above. Consent matters when the patient is medically/legally competent to make decisions and give informed consent. If they are not, then treatment is provided under implied consent that is considered to be in the patient's best interest and what most reasonable people would expect. 

Are there situations where a patient may be deemed incompetent due to their mental state but still be very aware and traumatized by the experience? Absolutely, and that is unfortunate.




Survivor2222 said:


> I get that there are timwspatients can’t think for themselves. Right now there are a number of lawsuits against law enforcement for forced catherizations on resistant patients, even times it was done in the name of health and not legal proceedings.
> 
> Consent needs to matter more in healthcare.



Not sure how many law enforcement officers are catheterizing patients...unless you mean blood draws. Usually those are being performed under a warrant.

And unfortunately we live in a litigious society that can sue you for everything you did or did not do. In many situations are you damned either way.


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## Tigger (Jul 10, 2018)

Survivor2222 said:


> Consent needs to matter more in healthcare.


Informed consent needs to matter more. There was no way for this to happen with this patient.

What do you suggest for a better alternative?


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## Survivor2222 (Jul 11, 2018)

Google. You can find many cases in many states where courts have rules that forced catherization of drunk patients is a violation of patient rights. 

There are hundreds and of cases like this all over the country. Nah, it doesn’t work to try to wash away the harm that savior complexes do by saying it’s a litigious society. 

People get drunk. 

You don’t always have to save them against their will. 

Let them be drunk. Let them say no. So what? 

What, you think that forcing your good on them will cure them of alcoholism? Nah. All you do is spin the cycle more. You see them one moment, one night, one day. You don’t have to deal with the aftermath of what the patient lives with when this traumatizes them. 

My colleagues and I follow them in all the aftermath. I have yet to run into a single client that said, “gosh I’m so glad that hospital forced care on me that I didn’t want while drunk.” 

That’s not said.

I have been to the gravesite of one who the retraumatization they face at the hands of people who’d toced themselves into his body while he was drunk led to him ending his life. 

I have helped on a Cade of one very bright deaf woman who had multiple procedures forced on her against her will because they assumed her deafness meant she was incapable of consent. She had a UTI. That’s it. They deemed her request for an interpreter invalid because she could speak, and spela well. But they also deemed her incompetent of making her choices. 

She was fully able to consent. 

These situations abound. 

Rarely are forced medical procedures done with any respect. The laughter and verbal abuse of patients in distress was ridiculous. 

Most addicts are trauma survivors. If you choose you make the choice to force your will upon them, do it with regard and respect for the cost of that on them. Yes they made their choices, you don’t need to make it worse. I am the one who has to help them pick up the pieces for the months and years to come afterwards. 

If you are going to take over the will and control of other humans, understand it comes with a very severe cost.

And know, the tide is changing. Consent is going to matter more and more. Not less. It’s time for healthcare to let patients be more responsible for their choices. It’s time for healthcare providers to have a much greater respect for the value of consent. 

If you just want to keep doing what you are doing... you will...


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## PotatoMedic (Jul 11, 2018)

Survivor2222 said:


> Google. You can find many cases in many states where courts have rules that forced catherization of drunk patients is a violation of patient rights.
> 
> There are hundreds and of cases like this all over the country. Nah, it doesn’t work to try to wash away the harm that savior complexes do by saying it’s a litigious society.
> 
> ...



You are correct, there have been many lawsuit proving that forced Cath of a drunk patient is not right.

But I do not believe we are talking about the drunk guy who got dragged into the ER because he is hardly responsive to verbal stimulation and swinging at staff because he is an a**.  The times I have seen "forced" caths performed is when we have an agitated violent patient who is having a behavioral crisis and we need to know what if any drugs they are on, or the patient who took an unknown number of drugs and is semi lethargic but still semi responsive.

You are right, for the purely drunk guy... Let them be drunk.  But we are also legally required to only release them when they are able to care for themselves, and when they are in the hospital we also cannot just let them die.

My advice to you is to not join a community to attack us.  If you want change be constructive and not accusatory.  Maybe it is just how I'm reading it at midnight but your posts seem to have a strong agenda without much constructive dialogue.


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## Survivor2222 (Jul 11, 2018)

I do have an agenda. To make it clear: consent needs to matter more than it typically does. 

My agenda doesn’t make my position invalid.


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## Akulahawk (Jul 11, 2018)

Survivor2222 said:


> People get drunk.
> 
> You don’t always have to save them against their will.
> 
> Let them be drunk. Let them say no. So what?


I'm an ED RN. We don't go a single shift without having drunk people show up. The vast majority of the drunks we see aren't the folks that get a bit drunk and are still somewhat functional. The majority of the drunks we get are the ones whose BAC is at _least_ 4x legal limit. Most of these drunks can't stand, let alone put together a coherent thought. Most cannot come close to articulating a plan of self-care when they arrive. Do we catheterize seriously drunk patients? Yes. All the time. Do we catheterize _all _drunk patients? No. If the drunk person can follow directions, they can provide the urine sample themselves. Why do we need the urine? We need to know quickly if there's something other than ethanol in their system. A urine drug screen provides this information very quickly. If we need a definitive level, we can get it from blood but that can take a while.

We also can't turn them away. That's an EMTALA violation because they're now on hospital grounds. I don't suppose you're advocating that a hospital break the law and incur significant fines because you want them to leave a drunk person alone, are you?

Until the drunk patient is sober enough to be able to articulate a plan of self care that's workable (and, if they're still legally drunk, have someone that can come get them), the hospital is required to keep them and provide care for them. We put those patients into a very special category: "Metabolize to Freedom." Once they're sober enough, out the door they go. Do note that I didn't say "completely sober" but rather "sober enough." 

For that matter, you could replace "drunk" with "high" or be regarding any number of intoxicating substances. 

Here's another side of the problem you might not have considered: Substance Abuse patients can also very commonly be Psych patients that are attempting to self-medicate. People that are having an apparent psych issue could very simply be having a substance abuse/toxicity problem. Methamphetamine psychosis happens. It's actually pretty rare that we see a psych patient that's having an acute psych issue that isn't also positive for one or more drugs and I'm not including THC on this... I've been an in an urban ED and I've had ONE patient that was acutely psychotic that was completely clean. One patient. 

Most of those patients know the routine and it includes providing a urine sample. The vast majority know they'll have a positive drug screen. We don't cath most of those unless they're combative and have to be put into restraints (standard of care) or are lethargic enough that they can't stand or sit unsupported and can't follow directions well enough to provide a urine sample (standard of care). How many of them end up with an actual foley cath? Very few. Most are either straight cathed or they're I/O cathed. 

Is providing necessary care and doing necessary procedures always "nice"? No. Will I force a procedure on someone that is able to refuse? No. Is forcing certain procedures and "care" upon people sometimes necessary? Yes, under certain conditions, and I will do it when necessary. 

Now then, when someone is able to refuse the care and they actually do refuse, even if refusing is a very bad thing, we allow them to refuse. We teach them what they need to know (and we often do very in-depth teaching on this) so they can refuse with full knowledge of what will happen if they refuse. I've had patients leave AMA, and I knew they'd be back _somewhere_ within the next 24 hours because their symptoms would be worse and would likely die because of the delay of care caused entirely by their own choice.


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## StCEMT (Jul 11, 2018)

Where do you get the idea that consent doesn't matter to us? My patients are more than welcome to refuse my interventions. It has happened many times before. They can refuse to be seen at all. I have had many refusals that I have no doubt had negative consequences or eventually were seen due to what was going on. In any of the above situations, as long as they can make informed choices then they can do as they wish. I'm not interested in fighting people who adamantly refuse to listen to what I have to say.


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## PotatoMedic (Jul 11, 2018)

Survivor2222 said:


> I do have an agenda. To make it clear: consent needs to matter more than it typically does.
> 
> My agenda doesn’t make my position invalid.


Let me state my last paragraph again.

My advice to you is to not join a community to attack us. If you want change be constructive and not accusatory. Maybe it is just how I'm reading it at midnight but your posts seem to have a strong agenda without much constructive dialogue.

Now read it again slowly so you understand the part about having a constructive dialogue and not just attacking people.


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## Survivor2222 (Jul 11, 2018)

Healthcare providers need to value consent more. As a profession, as a field, there is a huge need for greater respect for consent. 

That’s not an attack on you. 

It’s interesting that you take it as an attack. So be it. I don’t control how you take it.


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## Survivor2222 (Jul 11, 2018)

Read it again slowly what I posted. Slowly. 

Because telling you to read slowly is clearly a sign of respectful dialogue?! Geez. 

Here’s a mirror.


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## Survivor2222 (Jul 11, 2018)

Moving on.

https://www.statnews.com/2018/02/05/larry-nassar-doctors-sexual-assault/

http://doctors.ajc.com/part_1_license_to_betray/

Are the authors of these articles by health care professionals and respected writers also attacking you personally when they declare there is a greater need for respect for consent and safety in the health care profession?

Is every person staying that forced procedures come at a cost to the person, sometimes symptoms of traumatization that causes years of suffering, if not worse, an attack on you? 

Or is it perhaps a statement of reality that you personally just don’t want to face. Because you would then have to wrestle with difficult feelings about choices you have perhaps made. I don’t know. 

But your defensiveness about the issue is interesting. There are a growing number of voices stating there is anneed for change. Because there is. 

My stating forced procedures can and do regularly cause lasting harm and expense and are generally done way too easily and way too often with little regard for patients is not an attack on you. It’s a statement of fact. 

If you disagree with my statement, by all means, please discuss. Don’t insult my intelligence my telling me to read slowly. Instead. Provide evidence and argument and discussion that I am wrong. That the many people standing up for change and a greater respect for patient rights are wrong. That all the courts that have ruled most forced catherizations are being done when they should not be. (Google what’s happening in South Dakota and California on the very issue of forced catherizations on cases just like the OP described here.) 

I don’t care if you insult me. Doesn’t change my opinion and the need for change so that fewer people are traumatized by forced procedures.


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## Survivor2222 (Jul 11, 2018)

https://www.aclusd.org/en/news/aclu-south-dakota-takes-legal-action-stop-forcible-catheterizations

http://bjsm.bmj.com/content/bjsports/early/2018/06/22/bjsports-2018-099403.full.pdf

http://www.urologytimes.com/modern-...ful-catheter-insertion-leads-bleeding-lawsuit

I find it stunning it a post Larry Nassau world that a community would be so resistant and defensive when someone suggests hey, before providers forced themselves inside someone’s geniltals, let’s make sure consent and dignity is being valued highly. Are there rare times when it can’t be obtained a procedure should be done anyhow? Yes. But there needs to be respect even in those times that’s what is being done is without consent and forced physical invasion into a body, even if it causes no harm, without consent can be extremely traumatizing. I am not even stating that forced procedures against someone’s will should never ever be done. I’m stating that it’s happening too often and with little regard for the common effect it has on people.

Many therapists are trained to be reluctant and hesitant to call for 911 help for trauma patients in a mental health crisis.

Do you understand this? Have you gotten outside the EMT world at all to see the long term effects? I have.


Therapists are trained to be very careful about hospitalizing patients with trauma histories because it’s written in textbooks that the process is traumatic and worsens symptoms - it does not help restore to health. It might keep someone alive, which is very crucial, but it’s expected they will have worse symptoms when they leave because of forced procedures and etc.

I’ve personally talked to ER nurses who do more forceful IVs and laugh at suicidal patients in crisis and forced caths on highly fubtional patients expressing they were suicidal. The medical record documents no out of control behavior just an expression of suicidal thoughts. There was no cause for the forced catherizations for the client that I talked to them about.

They did it anyhow explaining it is what they normally do. “She should have peed the in the cup when we told her to do so.” 

I still have the records from those conversations. 

Three years later this client refused chemo for a highly treatable cancer because they were so afraid of forced procedures being done again without consent. This patient will likely die of this cancer because they have been so traumatized they won’t access care for it. It’s totalky their choice too. 

Go ahead and continue the forced catherizations. 

As someone who has professionally dealt with the long term consequences of well meaning and not so well meaning EMTs pushing too quickly for forced procedures invading the gentials of clients against consent, I hope that perhaps someone here will read my perspective on the long term consequences of forced procedures and make sure it’s absolutely worth the risk and costs to the patient to do it against their consent.

And if you take that as an attack, that’s on you.


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## PotatoMedic (Jul 11, 2018)

Survivor2222 said:


> Read it again slowly what I posted. Slowly.
> 
> Because telling you to read slowly is clearly a sign of respectful dialogue?! Geez.
> 
> Here’s a mirror.


I know my comment was rude. But at midnight I didn't really care for how you tried to accuse us of something we don't even do.


Survivor2222 said:


> https://www.aclusd.org/en/news/aclu-south-dakota-takes-legal-action-stop-forcible-catheterizations
> 
> http://bjsm.bmj.com/content/bjsports/early/2018/06/22/bjsports-2018-099403.full.pdf
> 
> ...


Just as an FYI.  No EMT's and VERY FEW paramedics do Foley catheters or even anything that involves genitalia.    You might want to go to allnurses.com and start a non-constructive dialogue there.


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## VFlutter (Jul 11, 2018)

Regardless of your opinion, or of the potential PTSD forced care may cause, an intoxicated person is not legally able to refuse care. Plain and simple. Many of us may wish we could let the patient just say no or just let the patient continue their cycle but that is not the way it works.

And although a patient with mental illness whom chooses to take their own life after a traumatic event is tragic I am sure would be much less frequent then death and disability caused by incompetent refused care. 

I am glad you have records of bad nurses doing bad care. That is an issue that surely needs to be addressed, to those nurses. This does not reflect the overall profession. And not to defend those actions however as a therapist i am sure you know the rates of mental trauma, burnout, PTSD, on those healthcare providers who see these patients multiple times a day every day they work. 

I have seen true PTSD in ICU patients. It is horrible and truly unfortunate. Should we have let them die instead?


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## Tigger (Jul 11, 2018)

Survivor2222 said:


> Read it again slowly what I posted. Slowly.
> 
> Because telling you to read slowly is clearly a sign of respectful dialogue?! Geez.
> 
> Here’s a mirror.


Care to answer my questions?


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## Gurby (Jul 11, 2018)

One of my least favorite memories from EMS...

Respond for the little old lady who fell down and bumped her head, on coumadin, history of dementia.  Get to the house, turns out a visiting nurse called because patient “has fallen several times today, struck head, and is acting abnormally”.  Patient seems fine to me, doesn’t seem demented, no visible signs of trauma, really really doesn’t want to go to hospital.  When asked if anything is bothering her, patient points at nurse and says “she is”.  

Given the circumstances though we basically kidnap her, hold her hand all the way in and tell her it’s okay she’s just going to get checked out.  Hand off at the hospital, and before we even leave the ED I see patient crying and being wheeled off to CT with a brand new Foley in place.  I was like, well ****, I can see why she didn’t want to come in now.


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## Ridryder911 (Jul 11, 2018)

_Time to step out the trauma bay and get a breath of fresh air... _ Real world... There are many so called_ "procedures"_ that are necessary to perform baseline/values to diagnose and treat. Would you not obtain lab's because the procedure is invasive and _potentially _ cause psychological problems? Then again, did these so called patients _truly _ meet the true diagnosis of PTSD and not the typical litigation definition of having a " _bad experience or bad time" _ with the procedure or event?

Then in comes the attorneys *IF* one does not perform such tests to *properly* evaluate to diagnose... etc! Alike everything else it depends on the *situation.* Do you need a u/a  for stat return? Do I have hours to wait for a UDS .. no!  Want me to lolly gag to determine an etiology? If possible and if allowed I will make an attempt to get a void specimen, many times we want a cath u/a for many reasons.

Then comes the role competent. Unfortunately, just because one is able to talk, fight or even flatly refuse does not make one competent. Does the patient... _really_.. know all of the risks and _side effects _ of not having the procedure performed?...yadda.... yadda.. Risks outweigh the problem?.. Which side do you think litigation is going to go? How many physicians would testify against the current standard of care and those within the medical community?

Sure there are always _hungry attorneys_ and there are always hospital/insurance attorneys on retainer...

R/r911


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## Survivor2222 (Jul 11, 2018)

PotatoMedic said:


> But at midnight I didn't really care


Yeah. That’s what they say when they force a procedure on someone with a disability because why are too tired to wait for a sign interpreter or take the time to communicate. 

I will repay my position slowly for you. 

I never stated forced catherizations should end. 

I believe consent should matter more than it typically does and patients need to be treated with greater respect, even when you are shoving instruments in their gentials. Even when they are drunk or high or whatever. And we. Again. I used to work as an EMT. I’ve seen it all. I work with addicts who even get violent. 

I will repay once again, super duper slowly for ya.

I never stated that forced catherizations and procedures should end. Force away. 

That does not change this: 

Consent, dignity, and respect still needs to matter more than it does. 

Procedures can still be forced even if someone increases their respect for consent and the damage and costs that come when consent isn’t sought or a procedure goes against consent.


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## Survivor2222 (Jul 11, 2018)

What if first responders were required to increase training in how to descalate problems and communicate with those with disabilities and addictions better? 

75 percent of forced procedures that were done could have been less traumatic (and still forced on the patient) with better communication and deescalating techniques. It would have made the job easier. Most areas that increase this trading had a drop in forced procedures without a loss of solid life saving healthcare provided. 

Most first responders could benefit and do their jobs better with greater training in deescalating   problems. There is also the problem of first responders doing things like joke about patients in front of them. Simple things I saw happen all the time. The few (yes I stated few!) that are jerks to patients do rest damage because everyone else is silent or back them up or gets their panties in a bunch like here when someone suggests hey, we could do a better job. 

There is no culture of saying “hey, that’s not ok” to someone who is an *** to the patient. I have never ever seen someone stop a colleague who wasn’t being a jerk. 

This field is not immune from fault and need for improvement.


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## Survivor2222 (Jul 11, 2018)

Who knew stating patients deserve respect would get so much push back? Holy cow.

Consent should matter more than it typically does.

Continue to do forced procedures. I have not stated they should stop. 

I have stated the value the profession as a culture places on consent and the weight given to a choice to go against it, should increase. 

No one has made a solid argument against this. What, you are going to say we should respect patients less? Ignore their personal responsibility and choices more? You want to claim the profession is perfe t and does not need to improve unlike all other professions on planet earth that are working on improving their ethics? 

That’s the hill you really wanna die on? Ugh.


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## Survivor2222 (Jul 11, 2018)

What four abilities must a patient show to be able to have capacity to give or refuse consent?


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## VFlutter (Jul 11, 2018)

Please quote a study showing 75% of forced procedures could have been done less traumatically, how you qualify that, how this training actually reduced the number of procedures, and how you related that to medical outcomes.

You are basically saying that the majority of us need training on an important topic we deal with everyday, that we all sit back and watch unethical treatment without issue, and that the culture of the entire profession supports that since you have never seen otherwise. I wonder why anyone would be offended.

Of course this field is not immune from fault, no profession is. You think all therapist are ethical and have their patients best interest in mind?

Not to make an argument from authority, which I hate, but could you describe the educational requirements to be a trauma therapist? Are you a MSW, LCSW, BS, or some type of license therapist?

You said you briefly worked as an EMT but it does not sounds like you have the clinical experience to make some of the generalizations you have made.



Survivor2222 said:


> What four abilities must a patient show to be able to have capacity to give or refuse consent?



. I don't know. Please educate us.



Survivor2222 said:


> No one has made a solid argument against this. What, you are going to say we should respect patients less? Ignore their personal responsibility and choices more? You want to claim the profession is perfe t and does not need to improve unlike all other professions on planet earth that are working on improving their ethics?
> 
> That’s the hill you really wanna die on? Ugh.



No one is arguing that.

You are the one trying to argue from your high hill of moral superiority.

It is great you are passionate about this topic but it is coming off as you venting about a personal vendetta vs actually trying to to productively inform and educate.


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## Peak (Jul 11, 2018)

@Survivor2222 You clearly have some ulterior motive. You are also persevering the same statements about "respect" despite the repeated attempts of members trying to explain their experience and knowledge. You have not come for a conversation but rather to come and stand on your soap box and project the opinions and bias that you come with. Posting what has been mostly news articles is anecdotal evidence at best, of which there is plenty of about abuse from mental health workers on their clients; making sweeping generalizations about an entire field of professionals wouldn't be fair or reasonable. I'll be honest, I've work alongside  many LCSWs, LPCs, psychologists, and psychiatrists when in the ED and other units of the hospital; your statements don't remind me of a professional who works in the mental health field but rather of a former patient with a vendetta.

If a patient presents in an altered mental state then we need to evaluate why they are altered. If there is no clear etiology then we may need to do further testing which may include blood work, drug screens, CT/MRI imaging, et cetera. If they are unable to understand the risks and benefits of treatment, then they cannot refuse; this is regardless of if they are heavily intoxicated, high, have medical disease process, are psychotic, et cetera. As medical providers we have a responsibility to be the lease invasive as possible, but we also have a duty to the patient to provide them efficacious care in an expedient manner. I cannot go to court and tell a jury that I let a patient herniate and die because they didn't want a CT/UDS/IV despite that they were incapable of refusing, I would have failed my duty to that patient.

From an ethical/moral standpoint I don't hold a lot of sympathy for those who become highly intoxicated or high and present to the ED and need a straight cath as part of their work-up. Their decision to drink or consume drugs to the point in which they can no longer control themselves is a decision that they made, they just now have to face the consequence of it. Behavior has consequence. 

I do feel bad for those with true psychosis, organic brain disease, or are altered because they have been victimized by another person. My duty to them doesn't change though, we still need to give them the same medical care. In my experience in the ED these are far less common than those who are altered because they decided to ingest substance.


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## Ridryder911 (Jul 11, 2018)

We can always improve, no one says differently. Should we be more empathetic? Definitely. At the same time our clients/patients etc. should also understand with the patient rights there are also patient responsibilities (_which many forget)._ Yes, in the past few years it has been an issue to promote different ways to address those with mental illness and how to approach patients.. (_as per JCH)_. I have witnessed too many times; patients being "bulldogged" into things and alike patients taking advantage of the situations as well.

Determining being competent is much more difficult than just asking them if they know day/time/situation/location as many feel is needed. Albeit, we do not usually have the time or be allowed to do a detail assessment to conclude. I always ask patient questions in regards in the information I shared and ask to repeat back or questions that they understand what I have informed them... and document it!

In regards to the initial post.. I ask; other than the patient with urinary retention.. "_who wants to be cathed?"_ ... Would we raise the fuss of a burn patient, trauma, sepsis or even a patient that will be immobilized for a period of time? .. What if they refused and are totally alert? Unfortunately, most of those within the EMS arena are not taught or understand the necessityof such things of a U/A. The description of a elderly crying is sad but again; what if they had missed an UTI or dehydration causing her fall? (Which is very prominent in gero falls) 

I have forced catheterized many patients due to injuries or illnesses that require a strict I/O or required a cath u/a. Personally, don't like catheterizing kids because of the fear factor but institution requires cath u/a. Sorry, clean catch or mid stream and wee-bag is not comparable.from a cath u/a..

As clinical providers we attempt to inform our patients and respect their wishes as much as allowed and possible.. but there are times that it is in the patients *best interest. *Although uncomfortable; and if possible to explain the need and with empathy (lido jelly) I usually can convince the patient; but there are times we I have to go in ... alike many other procedures .. ABG, NG tubes, etc... There are much more painful procedures and tests in comparision (yes, I have had to be cathed) Again, would we not place an NG tube on an OD? Again *reality* *check; *how many OD patients agree with getting an NG tube?...


R/r 911


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## VFlutter (Jul 11, 2018)

So a patient decides to use illicit narcotics. They are aware of the benefits, the legal consequences, and potential bad outcomes and choose to do so anyway. Are they are capable of understanding long term effects of those decisions. Doesn't matter I guess. When they are found overdosed we should let them die peacefully since we are respecting their informed consent to use drugs and any potential intervention would likey be traumatizing.


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## vc85 (Jul 11, 2018)

I agree with the others that are on here. @Survivor2222   what are your credentials?  And don't say 'trauma therapist' because that is not a license or degree. Are you a Ph.D./Psy.D;  LCSW; LMHC; LMFT?

Secondly, and this applies to law enforcement too; de-escalation is an easy thing to yell in protest. It is a hard thing to actually do; especially when the person is altered mental status. 

Let me ask you this. Say you're family member (young kid, Alzheimer's, intellectual disability or whatever) trips through a glass furniture object and severs an artery leading to massive hemorrhage. Because of their confusion and lack of blood to the brain they keep swinging at you and saying don't touch me. What would you do:

1. Do nothing and allow them to die in front of you

2. Try to deesclate the situation and talk them into consenting; during which they bleed out

3. Realize that because of their condition they are not in their right mind and are not capable of understanding what is happening and treat them anyway saving their life 

I understand you saying there needs to be more respect in healthcare and that some doctors are very authoritarian/paternalistic and don't explain things to patients (which does lead to bad outcomes)

HOWEVER, conflating criminal behavior like Larry Nasser with real medical procedures doesn't help your case and makes you seem extremist in your views


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## StCEMT (Jul 11, 2018)

Strawman arguments and unsupported statistics. Guess it's time to bow out.


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## Akulahawk (Jul 11, 2018)

Given that we've probably completely beaten this particular long-deceased equine enough and that Survivor2222 hasn't produced/cited anything beyond news articles and that there's been significant push-back by well-recognized and learned members of this community asking said member to produce said information so the rest of the community can verify claims, I'm closing this topic until such time that it is deemed appropriate by a CL to reopen this topic.


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## Chimpie (Jul 11, 2018)

@Survivor2222 First, welcome to EMTLIFE. 

Second, some advice from a Community Leader and an Administrator that I'll leave public for you and any new member that comes across this thread:

It's fine to be passionate about a topic and discuss it at length. And we're okay with posting in an old thread only if you're providing relative information about the subject. However, when asked to provide facts about your position, you said, "Google." That's not how to gain the respect of others in our community. 

Most of the users have been here for several years. Some more than a decade. Coming in as a new member and keyboard-ranting a point will result in you being questioned. Not to mention that you seem to be misdirecting your frustrations by targeting the wrong audience (pre-hospital). 

As for the thread, it will remain closed for the time being. And per our rules, if we close or remove a thread, don't create a new one with the same topic.


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