# saving lives?



## Veneficus (Oct 26, 2010)

Perhaps I should get a blog... But who would be able to find it or want to read it?

But in the meanwhile perhaps I can spur some discussion here.

On my medical journey over the last couple of weeks, I have been seeing dead people. As of this writing, only one has decided to stop breathing, but from my first contact, it wasn't a stroke of genious to figure out his race was run before the labs and xray came back. 

Though I do admit he "outlived" my estimate by about 12 hours. 

At one point in my absence I was told providers started CPR on him. My question was "why?" The answer was a long silence before a senior doc said "that's what we do." 

When I first saw the pt, important findings for this discussion; GCS was 1,1,4 (6) He had an accelerated ventriclar rythm with low amplitude qrs, diminished heart tones, a history of lung ca, his right lung was totally occluded, his left diminished, and on dopamine, his BP was 60/40 and he had no known family to even contact. (not that anyone made an effort to find any) 

For all intents and purposes, it was over. Even the ICU didn't want him, so he was admitted to a medicine floor.

Several other patients I saw were in a hematology ward. While Heme is supposed to be all blood disorders, the only people there at the moment are Neoplastic patients. It seems that is who are usually there (aka some form of leukemia or lymphoma) 

Many will never leave the hospital. The providers and patients try to keep spirits up, but there is a lot of smiling and pretending to not know things in front of them. 

I had the opportunity to look over a request to a drug company for free meds that are not demonstrated to work but cost tens of thousands. It is not even palliative care. It is protocol driven medicine. These people actaually have blood work drawn once a day.

Start at point A, decision tree to point B. If not, then decison tree to C.

In all fairness some of these patients actually benefit and will be leaving for productive lives. Some young, some old, but with things left to do.

But what about the ones who will not be returning home?

On most days I just want to tell them to get the hell out of the hospital, spend the remaining time with friends, family, skydiving, or whatever they have the strength left to do. Unfortunately I am not in the position to do that. When I ask the powers that be to they look at me like I am crazy after admitting they have no hope and have never in their collective experience seen these types of patients go home alive. Patients that can still walk and talk today. Who spend hours starring at a TV, hoping to be visited by friends or family, reading, and generally trying to pass time between meals, chemo, and blood and bone draws.

Is it crazy to urge dying people to live rather than sit in a hospital that knows they cannot help and die hoping for a miracle?

(In fairness it is not just this hospital, it plays out everyday in many countries)

This protocol crap really needs to go. It sucks. It makes no sense. It doesn't help. How did this madness ever become standard?

How does this relate to EMS?  

It relates to all healthcare everywhere. Whether you are deciding to terminate efforts, not start efforts, or run the dialysis derby on patients being hacked away a limb at a time. 

How did we get here? Where did we lose our way? Where are we even trying to go? What is your take on this? Does anyone else even see the madness?


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## terrible one (Oct 26, 2010)

I agree with you. I have no idea how these people (who are at the end of the road) just sit in a hospital and wait to die. I pray to God that myself or family never has to go through that, wether on the sidelines hopelessly watching or the one on the bed hopelessly dying. 
I don't know if I could ever work in a hospital and witness that day in and day out. Atleast on an ambulance you only have to play the carrade up until you pull into the ER, con home, diaylsis center, etc...

Good post.


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## TacoMEDIC (Oct 26, 2010)

I've got nothing to contribute to that. I think you covered it very well. I think that at times many of us feel the same way. 

Good post


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## Seaglass (Oct 26, 2010)

In my ideal world, doctors would be entirely honest with their patients. That means no sugarcoating, or pretending not to know that their chances are slim. That means telling them that when they check into the hospital for that course of treatment, they're trading a more active and pleasant death for a slow withering that isn't all that likely to cure anything. 

Some of them will still grasp at that little chance of beating the disease, and I think they should have that option. Some of them will prefer to go home and die in a nicer manner, and I think that's fine as well. 

If they can't speak for themselves, it becomes a lot stickier. I think that assuming they'll all want heroic measures taken is as fair of an assumption as any, though.


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## Smash (Oct 26, 2010)

Veneficus said:


> How did we get here? Where did we lose our way? Where are we even trying to go? What is your take on this? Does anyone else even see the madness?



Our technical ability to "save lives" long ago outstripped our intellectual and ethical ability to recognize that just because we can, doesn't mean we should.

EMS needs to be involved in the discussion around managed end-of-life care but we as an industry seem to find this very unpalatable.


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## firetender (Oct 27, 2010)

Vene, 

Excellent post! Request permission to use in my EMS blog


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## FrostbiteMedic (Oct 27, 2010)

I think that a little of our soul goes to each and every one of those patients. Having that dialysis patient that you transport every other day for two years, only to show up to get them one morning and be told by the family that they passed during the night, yeah, that hurts. To say that it is completely possible to do this job without ever getting emotionally attached to someone is to say that this job requires no heart, and I refuse to believe that this is a heartless job.


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## MrBrown (Oct 27, 2010)

*Brown puts down his phytochemical rich cancer defeating immunoboosting salad

Hmmm ..... you are correct good sirs, we have become so technically proficent at whizbang technological medicine I think the moral and ethical implications of what is done have long been tossed by the wayside

By the way, green cures cancer, they just don't want you to know that so its not out yet


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## Veneficus (Oct 27, 2010)

firetender said:


> Vene,
> 
> Excellent post! Request permission to use in my EMS blog



use it as you see fit


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## fast65 (Oct 27, 2010)

I'm not really sure what to say to that, however I did want to say that this is an amazing post and reading it has further inspired me to be the best healthcare provider that I can. Thank you for another piece of inspiration.


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## firetender (Oct 27, 2010)

*What are we?*

Vene, I know you as an extremely dedicated man who, even while juggling enormous responsibilities and a family AND medical school in a different country still works incredibly hard to share his knowledge and experience with EMTs learning the ropes. I can't thank you enough for your dogged determination to contribute!

I will be expanding on this topic in my blog, but for now, I want to speak directly to you.



Veneficus said:


> Perhaps I should get a blog... But who would be able to find it or want to read it?


 
EMSBlogs.com  Your POV is invaluable! Watch what happens with this!



Veneficus said:


> At one point in my absence I was told providers started CPR on him. My question was "why?" The answer was a long silence before a senior doc said "that's what we do."


 
That was as honest as he could have been, and accurate as well. I've been grappling, if not struggling with the very same themes, but from a different perspective. You see, most everything I used to save lives in 1980 have been debunked. Today, medics are using stuff in the field expressly because, through guys like me (and the patients I unsuccessfully treated, if not prolonged their agony!), we learned my stuff was no good.

The medics on this site will discover 25 years from now that what they're using today was mostly no good (or going in the wrong direction) as well. This is not a curse, it is scientifically grounded; science is beginning to tell us that aggressively "jump-starting" the body back into life is out and the next direction will be "slowing it down" through hypothermia and suspended animation drugs.

What a miserable situation; I was a vehicle through which not quite completely tested drugs and interventions were delivered to patients who were, essentially, guinea pigs without a right of refusal. This is our reality, Vene; well, not mine anymore, but this is what I was part of and set the scene for your generation to reflect as well!



Veneficus said:


> For all intents and purposes, it was over. Even the ICU didn't want him, so he was admitted to a medicine floor.
> 
> In all fairness some of these patients actually benefit and will be leaving for productive lives. Some young, some old, but with things left to do.
> 
> But what about the ones who will not be returning home?


 
They were part of an experiment that, perhaps ten years down the road may help someone like the above return to "productive lives".

YOU are part of an experiment. EVERYONE reading this is part of an experiment and, quite frankly, experimenters with a Lower Case "e". For the most part, you are testers of therapies that may or may not work, but some will.

In order to reconcile my life in EMS, I've had to come to terms with the fact that I was a reflection of mankind's insistence that it can beat death. 

Everybody believes that our science can prolong our lives and the way things have evolved is the overall culture of Western humanity, not just U.S. medicine (as reflected in your European training facility) gives us in the profession Carte Blanc to try EVERYTHING AND ANYTHING to keep people alive!



Veneficus said:


> On most days I just want to tell them to get the hell out of the hospital, spend the remaining time with friends, family, skydiving, or whatever they have the strength left to do. Unfortunately I am not in the position to do that. When I ask the powers that be to they look at me like I am crazy after admitting they have no hope and have never in their collective experience seen these types of patients go home alive. Patients that can still walk and talk today. Who spend hours starring at a TV, hoping to be visited by friends or family, reading, and generally trying to pass time between meals, chemo, and blood and bone draws.
> 
> Is it crazy to urge dying people to live rather than sit in a hospital that knows they cannot help and die hoping for a miracle?


 
No, it's not. In fact, it's much more sane than what you're doing and "you're" includes all the aggressive treatment that EMS prides itself on. Many, MANY patients are snapped back into lives that turn into emotional and financial nightmares because we got to them too fast or they got to the hospital too early.

YET, this isn't at all about sanity >>>




Veneficus said:


> (In fairness it is not just this hospital, it plays out everyday in many countries)
> 
> This protocol crap really needs to go. It sucks. It makes no sense. It doesn't help. How did this madness ever become standard?
> 
> How did we get here? Where did we lose our way? Where are we even trying to go? What is your take on this? Does anyone else even see the madness?


 
Western culture does not accept the inevitability of death. It is looked at as an "ending". It must be because if all the Christians REALLY believed they were going to Heaven, they wouldn't let their bodies be part of the experiment, they'd just relax, die and go home! (Just an example, folks-- eeeasyy!)

We, as a species, are programmed to fight like hell to stay alive. Period. That's reflected in our patient's willingness and our aggressive interventions. 

*Ultimately, it's pretty much the flip side of why we keep insisting on bringing NEW people into the world; it's hormonally driven!*

Medicine today, like it or not, is geared toward exploiting that survival drive. It's not for gain per se -- though let's face it, it sure makes the drug companies rich in the trying! 

Looking at humanity from the moon it boils down to our medicine of today trying as much as it can, as often as it can get away with it, on as many people as possible to EVENTUALLY build a body of knowledge that WILL allow us to beat death.

As long as no one is really acknowledging that "that's what we do" and protests, then the people will WILLINGLY subject themselves to the experiment.

So where does that leave us, my friend?

The most subversive question you or anyone on this site could ask today is "Why?" 

Right now, that question could drive you nuts, Vene, so let me try to help with perspective:

*Right now, as is true with the medics on this site, your job is not to question so much as to deliver. You are delivering "chances", some very few of which will stick and be applicable to the health and happiness of individuals in the future. In some cases, the chances you deliver may work right now!*

For you in particular, Vene, you've opened a Pandora's Box for yourself; but here's what I think.

You are a student directed and guided by a system that is doing things according to today's science. Today's science is impersonal. You are learning to be a Doctor, not a Healer. Healers understand that for many, embracing death is the best healing available.

You are gaining tools now. You are literally overfilling your tool kit so that you will have things to offer to the patients that you will end up treating. You really can't pick and choose your tools today, but you must get familiar with as many as you can.

*Perhaps the most important thing you're developing right now, as painful as it feels, is DISCERNMENT. Quite frankly, as long as the people buy in to the system you reflect you're not harming them, you're delivering hope; that's what they want from you; even when there is none. We're programmed to thrive on the illusion we may not die. *

(Let me thank you for helping ME to see this!)

Medicine as we are practicing it today is not really ready to hear that its practitioners want to start being with their patients in their life-cycles rather than placing all their efforts on delaying inevitable death. Unfortunately, a huge reason for this is that so many people make a living off of fighting death, let's face it, were we to drop the effort, the economy would collapse worse than GM and the Banks!!

But maybe you are part of a new generation -- all of you -- who are learning that giving patients a chance needs to include taking the time to consider; Is this a chance for life, or a chance for living?


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## TacoMEDIC (Oct 27, 2010)

Wow... Just wow. 

Well said :unsure:


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## FrostbiteMedic (Oct 27, 2010)

TacoMEDIC said:


> Wow... Just wow.
> 
> Well said :unsure:


Couldn't agree more


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## 46Young (Oct 27, 2010)

Great thread! It would seem that many of us share your sentiment, myself included.


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## Foxbat (Oct 28, 2010)

Seaglass said:


> In my ideal world, doctors would be entirely honest with their patients. That means no sugarcoating, or pretending not to know that their chances are slim. That means telling them that when they check into the hospital for that course of treatment, they're trading a more active and pleasant death for a slow withering that isn't all that likely to cure anything.



Nocebo.



> Writing from his extensive experience of treating cancer (including more than 1,000 melanoma cases) at Sydney Hospital, Milton (1973) warned of the impact of the delivery of a prognosis, and how many of his patients, upon receiving their prognosis, simply turned their face to the wall and died an extremely premature death: "... there is a small group of patients in whom the realisation of impending death is a blow so terrible that they are quite unable to adjust to it, and they die rapidly before the malignancy seems to have developed enough to cause death. This problem of self-willed death is in some ways analogous to the death produced in primitive peoples by witchcraft (“Pointing the bone”)." (p.1435)



A few decades ago it was a common practice in USSR, and perhaps other countries, not to reveal to patients the seriousness of their condition. For example, cancer patients were often told they had benign tumor, ulcer, etc. (while being treated for cancer) because fear and hopelessness had a bad effect on outcome.


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## Bosco578 (Oct 28, 2010)

Very profound. A truly great post against the tsunami of endless generic stuff........mine included.  Your spirit is strong.


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## firetender (Oct 28, 2010)

Foxbat said:


> Nocebo.
> 
> 
> 
> A few decades ago it was a common practice in USSR, and perhaps other countries, not to reveal to patients the seriousness of their condition. For example, cancer patients were often told they had benign tumor, ulcer, etc. (while being treated for cancer) because fear and hopelessness had a bad effect on outcome.


 
As an extension of this, in a clinical study of the effects of prayer on the prayed for (noted in Dr. Sanjay Gupta's book "Cheating Death") the patients who knew they were being prayed for did worse!


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## JJR512 (Oct 28, 2010)

Veneficus said:


> How does this relate to EMS?



I don't think it does at all. Last time I checked, EMS stood for _*E*mergency *M*edical *S*ervices_. In general, this is _out-of-hospital_ emergency care, and usually specifically, _pre-hospital emergency care_.

What you're talking about is in-hospital care. There are doctors, nurses, and other healthcare professionals to think about and take care of patient care once the incident report is signed in the emergency department. That's where the care, and the decision making thereto, ends on the part of EMS.

I recently started another thread here asking if anyone has ever gone to a funeral for a patient for whom they provided EMS but died, and the consensus there so far seems to be _No_, not unless the provider knew the patient personally. To paraphrase one person replying to that thread, "[Our] job is done once [we] get back in [our] truck and head to the next [patient]."



Smash said:


> EMS needs to be involved in the discussion around managed end-of-life care but we as an industry seem to find this very unpalatable.


It's not part of our industry. Our industry is keeping people alive long enough to get them to a hospital where someone else can figure out what to do with them. If possible, we can do certain things to make it easier for the next set of care providers. But again, once that incident report is signed and care is transferred, that's the end of it.

If anyone wants to take part in what happens _after_ care is transferred, hey, I'm all for it. Be my guest by all means. Go to medical school or nursing school, then get a job in the emergency department, or deeper in the hospital. _Then_ post-EMS care can be your problem.

Don't get me wrong, now. I'm not saying that what happens to patients after EMS transfers care is great and perfect. I'm not saying there's no room for improvement. All I'm saying is it's beyond the scope of what EMS is.


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## SanDiegoEmt7 (Oct 28, 2010)

JJR512 said:


> I don't think it does at all. Last time I checked, EMS stood for _*E*mergency *M*edical *S*ervices_. In general, this is _out-of-hospital_ emergency care, and usually specifically, _pre-hospital emergency care_.
> 
> What you're talking about is in-hospital care. There are doctors, nurses, and other healthcare professionals to think about and take care of patient care once the incident report is signed in the emergency department. That's where the care, and the decision making thereto, ends on the part of EMS.
> 
> ...



I can't believe you missed the point of what he is saying here.  His post is 100% related to EMS.

He is talking about modern medicine's desire to treat every patient by what the big book of medicine says, when half the time there's no benefit and it only has a negative impact on the patients' lives.  This is true in EMS as well.  I ran a call for a patient that had been in a coma for 40 years, on a ventilator, called out because she coded (she's a full code) managed to get her back on the way to the hospital, she was release back to her SNF 5 days later.  What's the point of that?  

Just because we treat patients should we go to their funeral? No.  What that has to do in a discussion of the validity of our dependence on protocol driven patient treatment, is beyond me.

The last part of your statement is exactly why the advancement of EMS is so damn hard.  The lack of desire to be part of the entire healthcare team.  Do you think the emergency department says to the ICU/med surg floor "My job is EMS, I don't care what happens to the patients after they are out of my department, they're only here for a little bit, I treat them off my protocols, and they are all yours"?


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## JJR512 (Oct 28, 2010)

SanDiegoEmt7 said:


> I can't believe you missed the point of what he is saying here.  His post is 100% related to EMS.



No.

At one point, the OP is talking about telling patients _in_ the hospital to get out of the hospital and go live what little lives they have left. I'm all for that, but that's not EMS. Once they get admitted—once an EMS provider gets the patient to the hospital—we have no business telling them it's now time to leave where we just brought them.

EMTs and Paramedics aren't doctors. It's not up to us to decide if the patient is best-served by being left at home or getting taken to the hospital. Our job is to get them to the hospital where someone else can figure that out.

If the patient doesn't want to go, they should refuse to go. If they're not capable of competently refusing, then...well...that's a problem, sure. That's a specific problem that _does_ affect and involve EMS, and that's one I'm all for trying to figure out how to fix, sure.



> He is talking about modern medicine's desire to treat every patient by what the big book of medicine says, when half the time there's no benefit and it only has a negative impact on the patients' lives.  This is true in EMS as well.  I ran a call for a patient that had been in a coma for 40 years, on a ventilator, called out because she coded (she's a full code) managed to get her back on the way to the hospital, she was release back to her SNF 5 days later.  What's the point of that?


Again, it's not for an EMS provider to say what's the point of that. Well, we're perfectly able to say what we personally think about it. What I mean is it's not our decision to make. We're not doctors. We can't decide on the spot that there's no point trying to save this patient, I mean we certainly can't _act_ on any such decision (and believe me, I agree with you, I'd be thinking the exact same thing myself if I was in that position).  



> Just because we treat patients should we go to their funeral? No.  What that has to do in a discussion of the validity of our dependence on protocol driven patient treatment, is beyond me.


Now who if failing to comprehend what someone wrote?

In this thread, I never said anything about going to a patient's funeral. I only mentioned that thread to tell you where I was quoting from.



> The last part of your statement is exactly why the advancement of EMS is so damn hard.  The lack of desire to be part of the entire healthcare team.  Do you think the emergency department says to the ICU/med surg floor "My job is EMS, I don't care what happens to the patients after they are out of my department, they're only here for a little bit, I treat them off my protocols, and they are all yours"?


I have no idea what an ED doc says to an ICU doc when care is transferred. I'm sure some, maybe many, do a follow-up check on their former patients later on. I know I've seen that happen in some of the hospital reality shows on the Discovery Health channel.

And I'll admit I'm often curious to know what happens to patients after they leave my care. Sure I wonder. But am I ever going to go find out what hospital room a patient has been admitted to so that I can go tell them they should get out of the hospital and enjoy what's left of their life? No. That's not for me to do, and it's not for me to decide. I don't know what's really going on with the patient, and even if I read the patient's entire chart I still wouldn't really know because I don't have years of medical school, internship, residency, etc. to interpret that chart and make that kind of decision.

So if you want to do something about protocols and cookie-cutter _EMS_, be my guest. Let me know if there's anything I can do to help. But again, once we transfer care, leave the doctoring to the doctors is how I feel.


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## SanDiegoEmt7 (Oct 28, 2010)

> JJR512 said:
> 
> 
> > No.
> ...


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## Aidey (Oct 28, 2010)

Ok so i'm on my phone, sorry for any typos. I also have a nice long reply to the OP on my computer at home, but I had to jump in now.

If what Vene is talking about isnt EMS, than apparently I don't work in EMS anymore. In whatever field I work in (lets call it EM for emergency medicine for :censored::censored::censored::censored:s and giggles) Vene's post is absolutely relevant.

He is advocating caring for people, you are advocating being a taxi driver. In my jobin EM I run into end of life issues all the time. What the pts baseline is vs what their prognosis is vs how sick they are now vs what kind of care they need to continue at an acceptable level vs what kind of care they want vs the pt or family wanting a natrual death. 

If someone has a problem but doesn't want transport it is my job to see if I can solve that problem or not and respect the patients wishes. It is not my job to just chuck them in the amb and let the doctor sort it out. Frankly as a medical provider in EM I'm insulted by your posts, and the insinuation I don't know enough to care for my patients without transporting them. 

We are the first line of defense to keep these people from being unnecessarily hospitalized. If we can help solve the problem right there we can save the patient and their family the trauma of that patient having to be transported. If a patient and/or their family don't want transport I will do everything within my power to assist them. Be it something simple like showing them how to use the pts nebulizer, to calling anyone I think can help. 

My job is NOT to transport people, my job is to provide medical care and take care of people. My job may or may not include transporting someone as part of that care. If you don't think that is appropriate, you can get out of my profession.


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## SanDiegoEmt7 (Oct 28, 2010)

Thank you for putting into words more clearly then I was able to.  That is exactly what I'm getting at.  It's late and I'm not all there.


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## Aidey (Oct 28, 2010)

No problem. I've had this discussion before unfortunately, so my speech is well rehearsed. This transport and turf attitude infuriates me.


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## JJR512 (Oct 28, 2010)

SanDiegoEmt7 said:


> He's not saying that he's not going to treat patients and tell them to leave.  He's was noticing to himself that he _wishes_ they would tell people these things, because its hard to watch medicine do absolutely nothing for people except consume the last bit of time they have left.  _This can be food for thought in EMS just as it is to hospital providers_


I understand that he wishes "they" would tell people these things. Keep in mind, though, that my entire response was in direct response solely to what I quoted from the OP, which was his question, "How does this relate to EMS?"

If the OP had left that one single line out, my reply (if I bothered to post one at all) would have simply consisted of, "You've said some things that I agree with, and given me some other things to think about." That's it.

I'm not saying that the OP is wrong, that I disagree with him, or anything like that at all. As I think I did actually manage to do at least once in my original reply, and as I indicated in the previous paragraph, I do actually agree with much of what he's saying. It's just that he asked how it relates to EMS, so that's what I answered. You were supposed to be able to tell that I was answering that question by the way I quoted it, and _only_ that, at the start of my first reply.



> Again, your taking everything at face value.  This thread was brought forth because it was the internal thoughts of a Medical Student who had a week of dead and dying patients.


First of all, taking what's written at face value is what I excel at. I am utterly useless at looking at one set of words and figuring out how the writer meant some completely different set of words. It's a skill that is beyond me. I'm sorry if that upsets you, I'm sorry if that compels anyone to call me stupid or lacking in common sense. Whatever.

(By the same token, I expect and demand that everything I write be taken at face value. I rarely make implications, and when I try, I usually fail. Do not ever "read between the lines" of what I write, because all that's there is blank space.)

As for the OP being a medical student, I didn't know that. I guess that explains why much of the original post seemed to be written from the point of view of someone who has been spending a lot of time inside a hospital!



> Using the fact that most people are not compelled to attend patients' funerals as evidence of our limited involvement and thought regarding patients is a moot point in my book.


Just as you continue to tell me how I'm missing the point, once again I have to say the same thing right back at you. In fact, I thought I had made it pretty clear that I wasn't "using the fact that most people are not compelled to attend patients' funerals" as evidence for anything. Once again, let me spell it out: I mentioned that thread only to provide a source citation for a quotation. The quotation itself was quite easy to adapt to my point in reply to the OP's question of what does what he was talking about have to do with EMS.



> Having discussions on the topics brought up by Veneficus doesn't me we don't do our job.  It just means, do your job but don't be ignorant about the prognosis of patients and modern medicine's ability to change that.  As a patient's often point of entry, *EMS is part of healthcare in my book* and as such the views of the "in the hospital" (as you put it) are important to me, regardless if I'm obligate to strictly follow my protocols.


Again, what I was discussing was solely related to the one thing he said that I quoted. I did not say that anything he said was wrong; I think I agreed with at least one thing he said, although at this point I'm no longer sure if that was in my first reply or second, and I'm not going to bother to scroll up and find out. I do know that I expressed some kind of agreement with something he said somewhere. And I'll say again that I am in general agreement with much of what was said, and there's plenty of stuff to think about. All I was addressing was the one thing I quoted, though.



> It has nothing to do with being cookie cutter.  EMS is required to be strictly protocol based because of the minimal training that we have received (thats entirely another thread).


It has already been the subject of _many_ threads.

But it did seem to me that strictly following some set of guidelines that tell you what to do is one of the key issues at the heart of what the OP was talking about. Like he wondered, why was CPR started on the one guy? Because that's what they do, the doc said. When the situation is X, do Y. It seemed to me that's something Veneficus was complaining about.

It's even like what you yourself was saying about the patient who had been in a coma for 40 years. Why transport that pt. to the hospital for arrest? Because that's what you do. Arrest = transport. Call the doc in the box, describe it to them, do they even need to think about it? Arrest = transport. Bring 'em on in. That's what the protocols say to do, right? That's one aspect that you and Veneficus are complaining about, right? The rigid structure of modern medicine? And let's be more accurate with that, too, by adding the word _Western_ in there somewhere.

And please note that I am, in general, agreeing with you.



> JJ, look, I'm not here to debate you protocols.  I'm not here to tell you to convince you patients to abandon hope with modern medicine.  I simply couldn't believe that you missed the point of Vene's post.


Again, it's not me that missed the point, it's you. The point of my reply was to directly answer only that which I quoted. See earlier in this post if you need further explanation.



> Just try to have an open mind to what he saying.  A great many problems with prehospital care, arise from the fact that paramedics and EMTs can't see past their protocol book and see the big (and perhaps depressing) picture.


My mind is open. I've already stated general agreement with much of what was said; how much more open do you need me to be?


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## SanDiegoEmt7 (Oct 28, 2010)

Veneficus,  I got side-tracked

Your post brings up valid points that I think any healthcare provider feels at some point or another,or maybe the during the entirety , of their career.  I've read somewhere, where is escaping me at the moment, that people who have worked in EMS prior to attending medical school typically have issues of burning out sooner than others during the clinical and residency years since they have already lost that naive ambition to cure the world.


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## JJR512 (Oct 28, 2010)

Aidey said:


> He is advocating caring for people, you are advocating being a taxi driver.


I'm not sure who this is addressed to. I'm assuming it's not me because you're usually not absolutely wrong, which is what you'd be if you _are_ addressing me.

I never said we should just drive people to the hospital.

What I was discussing can be boiled down to a concept expressed simply as, "After we have transferred care and left the facility, then our involvement with the care of the patient, whatever it has been up to that point in time, is concluded."

The way I interpret the "taxi driver" concept is, "Find the patient, toss them in the back and drive them to the hospital without providing any care at all whatsoever. The end."

The first concept is what I said. The second concept is what you for some reason seem to think I said. Do me a favor: Next time you want to tell me what you think I said, put the phone down first. I'm pretty sure you're really not so stupid as to think that these two concepts are the same thing. These two different concepts don't even involve the same frames of time.



> If someone has a problem but doesn't want transport it is my job to see if I can solve that problem or not and respect the patients wishes. It is not my job to just chuck them in the amb and let the doctor sort it out. Frankly as a medical provider in EM I'm insulted by your posts, and the insinuation I don't know enough to care for my patients without transporting them.


And I'm insulted by yours. Maybe you really are that stupid after all. Again, I never said EMS is a "you call, we haul" job. Absolutely we provide care. But that care ends at some point in time. Please understand that my post was directed at someone who was discussing things happening inside a hospital, and his question of what does that have to do with EMS. So most of my post was couched from the point of view of a patient who is going to the hospital. Now, of course not all patients go to the hospital. Regardless of if we transport or not, we do provide care for them, if they need some kind of care provided that we are capable of providing. Absolutely and of course! I'm not saying otherwise. Never have and never will. All I'm saying is that for a patient that we _do_ transport, once care is transferred, that's pretty much the end of our involvement, at least in terms of making decisions about their care. 



> My job is NOT to transport people, my job is to provide medical care and take care of people. My job may or may not include transporting someone as part of that care. If you don't think that is appropriate, you can get out of my profession.


Why don't you pull your halo out of your *** long enough to consider what it was I was actually replying to (hint: it was in a quote box at the top of my original reply), and the context in which the reply was given (hint: I mentioned that earlier in this reply), then see if I've ever actually _written_ (by "written", I mean actually directly expressed with words that you can see on the screen, as opposed to words that you mistakenly think you can interpret or find "between the lines" and even then only by ignoring the context) anything that justifies your final statement. (One final hint: I agree with your description of our jobs as EMS providers.)


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## JJR512 (Oct 28, 2010)

SanDiegoEmt7 said:


> Veneficus,  I got side-tracked


Yep, that can happen when you don't pay attention to what it is exactly that a reply is actually in reply to.

So getting back on track...


> Your post brings up valid points that I think any healthcare provider feels at some point or another,or maybe the during the entirety , of their career.  I've read somewhere, where is escaping me at the moment, that people who have worked in EMS prior to attending medical school typically have issues of burning out sooner than others during the clinical and residency years since they have already lost that naive ambition to cure the world.



Regarding the first part, I know (and in fact have already said in this very thread) that I've certainly felt that way at times. I have often wondered what is the point.

I've done a lot of inter-facility transports, and consequently transported a lot of people that seem to be no longer really in this world. I mean, mentally, they seem gone. Nobody's home, know what I mean? But then I wonder: How do I know for sure? How does _anyone_ know for sure, even doctors? Sure, they can measure certain things, do an EEG, but really, I don't think consciousness is very well understood.

This actually once got me wondering whether it would be better to retain normal mental faculties but lose all control over one's body, or for all body functions to remain essentially normal but for the mind to go. Personally, I think it would be horrible to be an intelligent mind trapped in a useless body. And I mean useless, utterly being incapable of expressing yourself or letting anyone know that yes, you really are "still home".


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## Aidey (Oct 28, 2010)

JJR512 said:


> EMTs and Paramedics aren't doctors. It's not up to us to decide if the patient is best-served by being left at home or getting taken to the hospital. Our job is to get them to the hospital where someone else can figure that out.



You do remember what you wrote don't you? Or did you mean something else by this, that we were supposed to pick up by reading between the lines?

I might not be a doctor, but that is exactly what my job is. My job is not to get them to the hospital where someone else can figure out whether or not they needed to be there in the first place.


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## jrm818 (Oct 28, 2010)

I don't think there's any question that this applies to EMS.  It's an issue of our focus.  Should our primary goal be preserving life?(as it generally is now, from what I've seen).  Or should it be alleviating suffering, and trying to improve quality of life (or mitigate loss of quality of life).

 "High performing" EMS systems are those that have the highest cardiac arrest save rate.  

Stroke is important to recognize because it is a huge cause of death (not because of the huge toll on quality of life for survivors).  

Pain control...eh...who really cares.  Nice, but they can wait, suffering for 20 minutes isn't that bad, they aren't going to _die_.  

Avoiding the hospital altogether?  Not our job (Even though I think we all know that granny smith who fell down is speaking some amount of truth when she says "I'm not going to the hospital...that's where people go to die.")



I also wonder how much the push to really focus on using evidence based medicine has to do with the obsession with preserving life.  I don't know nearly enough about the history of medicine to be able to evaluate if this is really a "new" push, it does occur to me though that the sort-of default primary endpoint in a lot of research (especially in EMS) is mortality. 

The choice of death as a research end point may be a reflection of a social obsession with avoiding death, may be due to the relative difficulty of evaluating quality of life improvements (its much easier (practically and mathematically) to evaluate the binary dead/not dead than it is to evaluate relative levels of depression, debilitation, pain, etc.) or may not even be as prevalent as I think.  But, if the research that informs our practice is so focused on death, is it surprising that the practitioners are similarly focused?


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## JJR512 (Oct 28, 2010)

Aidey said:


> You do remember what you wrote don't you? Or did you mean something else by this, that we were supposed to pick up by reading between the lines?


You do remember what that was a reply to, don't you? That's all you need to remember, no searching between the lines necessary.



> I might not be a doctor, but that is exactly what my job is. My job is not to get them to the hospital where someone else can figure out whether or not they needed to be there in the first place.



In specific regard to someone who is in cardiac arrest, someone who has needed CPR, they need to get transported. Regardless of whatever you can do for them in the field, they _also_ need to get transported. At least that's true where I come from, maybe your EMS system and protocols allow you to leave someone who was arresting in the field after you recover them, I don't know.

Context. Look it up. I'll be happy to quote what the OED has to say about it, if you'd like. Or you can get smart and get this thread back on track just like SanDiegoEmt7 and I did.


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## firetender (Oct 28, 2010)

*Clear the patient...ZAP!!! (360 Joules)*



Veneficus said:


> How does this relate to EMS?
> 
> It relates to all healthcare everywhere. Whether you are deciding to terminate efforts, not start efforts, or run the dialysis derby on patients being hacked away a limb at a time.
> 
> How did we get here? Where did we lose our way? Where are we even trying to go? What is your take on this? Does anyone else even see the madness?


 
This was the starting point; have we lost our way? What is really the WAY? 

I appreciate some who define where their roles start and where they end, but what I think Vene is seeking is "Are you conscious of more than your next call? Are you aware of the overall system of which you are a part? And maybe we ought to look more closely at the human beings involved and their Quality of Life."

 ALL of us are involved!

Hopefully, after this defibrillation the heart of this important conversation will beat again! It has not hit "Dead Horse" status yet, though some people seem to be working on hobbling it.

Wait...there's something coming up on the screen...


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## SanDiegoEmt7 (Oct 28, 2010)

JJR512 said:


> You do remember what that was a reply to, don't you? That's all you need to remember, no searching between the lines necessary.
> 
> 
> 
> ...



I apologize in advance firetender, particularly since your post reflects my own thoughts.

Just a point I'll make, then I'm leaving this thread forever.  NOT EVERY PATIENT WHO IS IN CARDIAC ARREST GETS TRANSPORTED.  Many patients are called on scene after being worked for a certain amount of cycles, since most EDs can't do much more in the regards of ACLS than paramedics.  Sometimes a transport is done out of consideration for the family on scene, its very traumatic for them to watch the decision made in their living room.

Perhaps your stance on the ORIGINAL ISSUE (read Firetender's post, don't attack me on ACLS) is due to you being an EMTB where you don't have the opportunity to make a great deal of decisions regarding patient care, because I think that's when the majority of people start to wonder why they make they decisions, albeit most likely the proper decisions set forth by protocol, that they do.

SDEMT out

and please don't tell me I'm smart for avoiding a debate with you, thanks


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## JJR512 (Oct 28, 2010)

SanDiegoEmt7 said:


> I apologize in advance firetender, particularly since your post reflects my own thoughts.
> 
> Just a point I'll make, then I'm leaving this thread forever.  NOT EVERY PATIENT WHO IS IN CARDIAC ARREST GETS TRANSPORTED.
> 
> and please don't tell me I'm smart for avoiding a debate with you, thanks



This is news to me. It's also news to some of the paramedics I just asked. Well, strictly speaking, you're right. If the patient is resuscitated and refuses transport, they don't get transported. If they die in a SNF or hospice, etc., they don't get transported. As I said, maybe it's different where you are. Around here, the concept of leaving a resuscitated patient wherever they were found arresting seemed shocking.

Regarding your last comment, I don't recall telling you any such thing. However, the tone of your comment doesn't seem to be like you're trying to avoid a debate, so after that, I wouldn't make such a comment anyway; no need to ask me not to now.


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## Veneficus (Oct 28, 2010)

JJR512 said:


> This is news to me. It's also news to some of the paramedics I just asked. Well, strictly speaking, you're right. If the patient is resuscitated and refuses transport, they don't get transported. If they die in a SNF or hospice, etc., they don't get transported. As I said, maybe it's different where you are. Around here, the concept of leaving a resuscitated patient wherever they were found arresting seemed shocking.
> 
> Regarding your last comment, I don't recall telling you any such thing. However, the tone of your comment doesn't seem to be like you're trying to avoid a debate, so after that, I wouldn't make such a comment anyway; no need to ask me not to now.



If I could just point out to add to the discussion I am enjoying passively watching. 

As far back as 2002 in my EMS employment, paramedics were deciding when to inititiate resuscitation or to discontinue it without online medical direction. 

In 2003 I was employed by an agency where a paramedic could refuse to transport a patient who fit the criteria of not needing emergent transport to an ED.

It is always important to consider the full spectrum of what is happening in EMS. That includes everything from the cutting edge to the bleeding edge, as well as what is happening in other nations.

The role of EMS is not restricted nor defined by any single locale.


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## JJR512 (Oct 28, 2010)

Veneficus said:


> The role of EMS is not restricted nor defined by any single locale.



Indeed it is not. Hence my original qualifier of, "At least that's true where I come from, maybe your EMS system and protocols allow you to blah blah blah."

And I agree with paying attention to what other localities are doing, as long as a provider is careful to not let that get in the way of them dong what they're supposed to be doing according to their own local protocols and scope of practice. Now if something that somewhere else is doing seems more intelligent and makes more sense than what you do locally, by all means, point that out to your local EMS management. Try to get your protocols and scope changed. Obviously, one would need a bit more conclusive proof that the other place's ways are superior besides that it's just what some dude on some internet forum said.

I am not yet at a point in my education and experience where I can intelligently evaluate studies and reports and analyze how other methods/practices/policies/whatever are better than my own. But I do keep an eye on EMS news when I get a chance, and I read a lot of things that sound very interesting in terms of research and advancing EMS.


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## Veneficus (Oct 28, 2010)

firetender said:


> This was the starting point; have we lost our way? What is really the WAY? ...



I thought the way was to help people. At the very least "do no harm." 

The treatments for neoplastic blood disorders are the most perfectly designed witches brew of poison known to man. Designed by the doctors who spend their lives trying to improve and save peoples' lives to purposely destroy the cells a person needs to live.

It will cause harm. What I wonder is: when you know you are harming, physically, mentally, emotionally and economically, and in your collective experience and knowledge, the treatment is not shown to work or you know the patient is beyond that treatment, why do we go through the motions?

Is it better to live well for 2 years or suffer for 3 or 4? Where is the dividing line? What when the "treatment" you hope will work cuts it down to suffering for 8 months? 

I guess my real issue is the industrialization. Once a person is placed in the machine, the wheels turn, often without consideration or response until the cycle is completed. A system where the only outcome is normal or death. There is no middle ground.

EMS is not immune nor removed from this practice. Even before I went back to school I could tell you a kid who went into cardiac arrest was not coming out unless a very narrow set of circumstances were met. 

Costing a family tens of thousands of dollars they didn't have, delaying thier grieving process, spending resources other members of their family desperately needed, and absusing the corpses of their loved ones, didn't help them nor me. 

Why do people advocate that?

I don't really think it is a question of burnout. I see it as questions that need to be reconciled. 

I also think the whole idea of protocol driven medicine is a wrong turn. Helping most of your patients the most often is not medicine. Helping all of your patients to the best of your knowledge and ability is medicine. Protocols just don't even come close. Even in EMS we know the common ones often cause harm.

What justifies the quest of making things easier on ourselves when it doesn't serve those who came to us for help?

It is not a matter of not knowing something future generations will that we don't. Nothing can change that. The real matter is why continue to do what we know won't help?


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## Aidey (Oct 28, 2010)

JJR512 said:


> This is news to me. It's also news to some of the paramedics I just asked. Well, strictly speaking, you're right. If the patient is resuscitated and refuses transport, they don't get transported. If they die in a SNF or hospice, etc., they don't get transported. As I said, maybe it's different where you are. Around here, the concept of *leaving a resuscitated patient wherever they were found arresting *seemed shocking.



Who the heck said anything about a resuscitated patient? I said that my job involves figuring out whether or not a patient needs to go to the hospital. A patient who has been resuscitated generally falls into that category. In some cases they may not be transported, it really depends. In my agency if someone is GCS 15 they can refuse anything, no matter what is going on. 

Here is a more realistic case, patient on Hospice, end stage cancer with mets everywhere, given days to live by Hospice, wants to die at home. When the patients mental status starts to decline the family panics and calls 911. Transport and let the doc sort it out, or try and sort it out at home?


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## Aidey (Oct 28, 2010)

I agree that it is very sad that people end up spending a lot of their  decent time left in a hospital. I think we got here several ways.

Somewhere along the way "Do no harm" became "Do not let die without  doing everything medically possible". Doctors aren't allowed to talk  about death, becuase death is the ultimate harm, and doctors are  supposed to avoid that. With advances of science and the internet a lot  of non-medical people feel that their loved one will become the next one  who beats the odds. If they don't think everything that can be done was  done they will continue to think that if that one thing had been done,  the outcome would have been different. 

It has been interesting reading information about the doctors working to  make palliative care a specialty, like EM, or OB/GYN. They have a lot  of evidence that people are treating themselves to death, making their  last days miserable. People who are on their 5th or 6th round of chemo,  and are receiving it up until the day they die. People diagnosed with  things like stage 4 pancreatic cancer who want to do everything  possible, when the remission rate is abysmal. 

The doctors themselves admit that they receive little to no education in  traditional medical school about end of life issues, and how to have  those discussions with patients. I remember one said that they found it  easier to just give the family what they wanted, even though the outcome  was going to be death and nothing was going to change that. 

Protocols offer protection. When in doubt it offers a safety net to fall  back on. It is a written example of what should be done, so providers  can say "well, I followed the protocol". Even if it doesn't stand up in a  legal setting, it makes people feel better because they can blame  someone other than themselves, "I followed the protocol, I don't know  why it didn't work". 

I think at its core this is a psychological problem,from EMS on up. The  script is transport, treat, do everything possible. When we deviate from  that it makes people uncomfortable because it makes us confront our own  mortality.


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## Smash (Oct 28, 2010)

It is very difficult to move past the technical imperative - that is we _can_ do something therefore we _must_ do something.  This seems to be particularly true in EMS due to the nature of the training over education model that is prevalent.

EMS most certainly should be involved in end-of-life care and decision making, far beyond the usual routine of "Bed bound, nappy wearing, persistent vegetative state, cancer ridden 80 year old has arrested, therefore commence CPR".  To me, that doesn't seem like doing no harm...

There are small glimmers of hope on the horizon for us making some rational decisions and having a positive impact on patients and families in end-of-life scenarios.  Personally I do not start resus on every cardiac arrest patient I am called to.  I certainly do not transport every cardiac arrest patient I am called to.  I am legally allowed to verify death in certain circumstances, thereby removing the extra strain on the family of having to get more paperwork done by other agencies or getting coroners involved and all the unpleasantness that involves.

We are also becoming more involved in better care for palliative patients who wish to remain at home.  We are forging stronger relationships with the doctors who oversee palliative care, and this is (slowly) resulting in more appropriate care.  For example we can administer morphine to patients with breakthrough pain and leave them at home to be followed up by the palliative care services.

These are small steps, but important ones to make, and hopefully they will lead to great bounds in our care for these subsets of patients.  End-of-life care is most definitely something we need to be involved more heavily in, as we are often on the "front lines" of caring for these patients and their families.

I undertand what you are saying Vene about the industrialisationof medicine.  The phrase I have heard and like to descrive this phenomenon is McMedicalisation.  Outcome becomes secondary to the process, and while we become more and more proficient at following a process, we become less and less proficient at actually managing a patient.  This is certainly the case in EMS where we continue to accept atrociously low levels of education in our providors, so we attempt to manage risk by making every patient fit into a predetermined protocol and writing more and more protocol to try to cover ourselves for every eventuality.  That way lies madness, yet we persist!

What can we do about it?  I don't know.  We are making our own small steps where I work, but it is hard to see how we can transform our entire industry to better cope with these sorts of issues.  Maybe we need to stop wondering whether a King is better than a Combi-tube, and start focusing on some real education instead, education that has a bit more of the humanities thrown in rather than just the sciences.


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## JJR512 (Oct 28, 2010)

Aidey said:


> Who the heck said anything about a resuscitated patient?



I did. It was part of an example scenario I used several posts back.

About the hospice patient, well I think I already mentioned hospice patients, too. More to that point, around here, it is my understanding that hospice patients are almost always DNR. So that patient probably isn't going to get transported.

There are always exceptions, no argument about that.


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## Aidey (Oct 28, 2010)

DNR or not has nothing to do with it, the hypothetical patient isnt in arrest.


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## JJR512 (Oct 29, 2010)

Aidey said:


> DNR or not has nothing to do with it, the hypothetical patient isnt in arrest.



Well the one I was talking about was, so whatever. Look, how much further do you want to continue this stupid pointless back-and-forth? Because I _will_ keep playing. But I'd much rather not keep cluttering up this thread with this ********; I'd much rather see more about the intended topic of discussion.


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## Aidey (Oct 29, 2010)

Ok, back on topic then.

You are called for a patient on Hospice, end stage cancer with mets everywhere, given days to live by Hospice, wants to die at home. When the patient's mental status starts to decline the family panics and calls 911. 

So what do we as EMS providers do? Do we try and follow the patient's wishes to stay out of the hospital or do we transport and let the doc at the ER take it from there? What is the role of EMS in this patient's case?


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## TacoMEDIC (Oct 29, 2010)

Aidey said:


> Ok, back on topic then.
> 
> You are called for a patient on Hospice, end stage cancer with mets everywhere, given days to live by Hospice, wants to die at home. When the patient's mental status starts to decline the family panics and calls 911.
> 
> So what do we as EMS providers do? Do we try and follow the patient's wishes to stay out of the hospital or do we transport and let the doc at the ER take it from there?



Our protocol indicates that the family may make the decision in the presence of EMS. Base Station contact is helpful in these scenerios. It never hurts to spread liability to higher level medical professionals.


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## Aidey (Oct 29, 2010)

That doesn't actually answer the question, remember family called. 

Do you transport based off of their panicked decision to call 911 or do you discuss the situation and find out if transport is truly indicated or if the problem can be solved another way?

Do you sit down, talk to the family about why they are panicked? Spend time explaining what is expected when someone is near death, maybe call hospice if they are involved or the pts primary? Do you offer any reassurance, or offer to help them with something they are too overwhelmed to do?


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## JJR512 (Oct 29, 2010)

I don't know what "mets" are but barring them being anything that would change my initial opinion, my feeling is that the exact scenario currently being discussed does not call for transport. I would discuss the situation with the family, as posed in the follow-up question. If the panic can be calmed, I would most definitely get a refusal signed. If the family is insistent on transportation, though, I would probably consult medical direction first. Since I'm unexperienced in these kinds of situations, consulting seems like a wise course of action.

If the family insists on transportation, I really have no idea what would happen. The hospice facility staff may try to show me advanced directives or a living will or something to that effect, but the only document that I am legally allowed to interpret and use as a means to stop providing care is a DNR. This patient in the currently-posed hypothetical situation isn't in need of resuscitation, though. And a DNR doesn't say anything about transporting. So if, due to being unsure of the situation, I do a consult, if I tell the doc in the box that the hospice has these documents, I don't really know what medical direction can do with that info. I can't tell if those documents are legitimate, so I can't tell medical direction that they're legit. I don't know if medical direction would want to talk to the hospice staff.

I have a sneaking suspicion, though, that medical direction would just take the easy way out, err on the side of caution (meaning making sure they're covering their asses), and order a transport.


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## firetender (Oct 30, 2010)

Veneficus said:


> I thought the way was to help people. At the very least "do no harm." ...why do we go through the motions?
> 
> Is it better to live well for 2 years or suffer for 3 or 4? ...the industrialization... without consideration or response...the only outcome is normal or death. There is no middle ground...Costing a family tens of thousands of dollars they didn't have
> 
> ...


 
Vene, you're lucky you're over there and not HERE! If you think you're hobbled now try adding insurance, co-payments Medi this that and the other, and out of every nook and crannie is waiting a lawyer poised to pounce as soon as you slip your scalpel! I'm talking PURELY money-driven. I suspect you still have a semblance of sanity over there!



Veneficus said:


> Helping all of your patients to the best of your knowledge and ability is medicine


 
Oops! that's where you missed the boat. Medicine is all about making it *look like* we know what we're doing and eventually can cure everything. Medicine, were it to allow its practitioners to do as you say would spend equal time on preparation for death as it would on diagnostics. The problem with medicine is it largely denies death.

The "We're doing everything we can" part is accurate. It's doing, doing, doing, regardless.

People want the best that money can buy and believe that going into debt is worth the gamble, figuring the more it costs the better the odds of success. They blindly say "Yes, yes yes!" when what they should be asking is, "Really, Doc...is the extra time gonna be worth living?"

And no Doctor will tell the truth because NO DOCTOR HAS THE ANSWER. None of it is up to us, so we're in a bind.

The practitioners get told the next big thing will make a difference, so they tell their patients, "We beleive this might make a difference."

The truth is, on some people it might and others it might kill. Our goal is not to lessen the pain and suffering of our failures, it's to produce an effect in the successes that does just a bit better than sugar pills.

I believe the poster who said you're butt is more likely to be twisted around since you didn't go into this naive.



Veneficus said:


> ...I see it as questions that need to be reconciled...why continue to do what we know won't help?


 
BINGO! it's something you and you alone must come to terms with. 

This is harsh, but if you are aware that something you've been told to administer or recommend will prolong suffering, then you have to make a choice that you can live with. One such choice could very well be, "I'll do what I'm told, learn as best I can how to be able to judge for myself better, and then work toward beang able to make more autonomous decicions as quickly as possible."

Vene, you, in particular are in a business where pain and suffering are often considered acceptable collateral damage in pursuit of knowledge.


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## firetender (Oct 30, 2010)

*...almost forgot...*



Veneficus said:


> The real matter is why?


 
Now, how does this apply to EMS? It doesn't, really.

It's a human thing about moral and logistical choices. It's about struggling in conflicts between your head and your heart. It's about being in extreme circumstances where lives hang in the balance and you have to make quick choices for people who can't for themselves and sometimes they are wrong. It's about circumstances where you may actually encounter the handiwork of your choices, brain dead in Neuro.

These are things we NEVER encounter in EMS.


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## Aidey (Oct 30, 2010)

firetender said:


> Now, how does this apply to EMS? It doesn't, really.
> 
> It's a human thing about moral and logistical choices. It's about struggling in conflicts between your head and your heart. It's about being in extreme circumstances where lives hang in the balance and you have to make quick choices for people who can't for themselves and sometimes they are wrong. *It's about circumstances where you may actually encounter the handiwork of your choices, brain dead in Neuro.*
> 
> *These are things we NEVER encounter in EMS.*



Not necessarily true. Where I live we have a true rehab hospital*, and it is entirely possible you will transport a former patient to/from there, be it the broken hip or the near drowning. 


* As in it is an actual hospital, not just a SNF that has rehab available.


Edit: You're being sarcastic aren't you?


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## firetender (Oct 30, 2010)

Aidey said:


> Edit: You're being sarcastic aren't you?


 
I'm from NY...it's a genetic defect!


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## Aidey (Oct 30, 2010)

It took me a min, becuase I could see someone trying to argue that we don't have to live with the consequences of our decisions in the field. Is it sad I could see someone arguing that seriously? Don't be offended I thought you were, I woke up early and didn't get a nap.


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## JJR512 (Oct 30, 2010)

Aidey said:


> It took me a min, becuase I could see someone trying to argue that we don't have to live with the consequences of our decisions in the field. Is it sad I could see someone arguing that seriously?



Yes. Well, perhaps it might be nicer to say that it's _realistic_ to understand that some providers could argue that, and _that_ is what's sad.


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## Veneficus (Oct 30, 2010)

firetender said:


> Vene, you're lucky you're over there and not HERE! If you think you're hobbled now try adding insurance, co-payments Medi this that and the other, and out of every nook and crannie is waiting a lawyer poised to pounce as soon as you slip your scalpel! I'm talking PURELY money-driven. I suspect you still have a semblance of sanity over there!.



Don't bet on it. Not all the systems here are social. Here you are required to have insurance. Which just like everywhere else wants to make money. The gov covers a rather sparce policy for those out of work. If something is not covered by insurance, the person pays out of pocket. If they can afford it. There is a limited charity budget and when it runs out it is gone for the year. On the lower plans you can see a GP anytime, bt even when referred to say, a nerologist, it can take months to get an appointment. Obviously the better your plan (aka the more you pay) the better your service. Still something is better than nothing. In special circumstances, a provider can make a case to the ministry of health to cover costs beyond what insurance would pay, but it is not likely to succeed. Providers also have taken to writing directly to various companies asking for charity direct. Which works better than the Ministry.

But the finer points of healthcare costs have already been argued on this forum, and I really can't take anymore pseudoeducated decisions based on half truths and political rhetoric on both sides.  




firetender said:


> Oops! that's where you missed the boat. Medicine is all about making it *look like* we know what we're doing and eventually can cure everything. Medicine, were it to allow its practitioners to do as you say would spend equal time on preparation for death as it would on diagnostics. *The problem with medicine is it largely denies death.!.*


*

yea, that is the part I can't get my head around. A bunch of really smart people pretending it doesn't exist. Could almost be a relious order.



firetender said:



			The "We're doing everything we can" part is accurate. It's doing, doing, doing, regardless.
		
Click to expand...


"You've done it I exclaimed with a scream and a taunt, it's just what I asked for, but not what I want."



firetender said:



			People want the best that money can buy and believe that going into debt is worth the gamble, figuring the more it costs the better the odds of success. They blindly say "Yes, yes yes!" when what they should be asking is, "Really, Doc...is the extra time gonna be worth living?"
		
Click to expand...


I think it is medical providers that pushed this and the patients caught on.

When somebody asks "what does this mean?" we often tell them about the science of it. Most people don't care, they want to know if they will be able to go back to work, walk, see, whatever. I always try to make a point of figuring out their concerns. It is within my power to answer honestly, and they seem to appreciate it more than a patho lecture.




firetender said:



			The practitioners get told the next big thing will make a difference, so they tell their patients, "We beleive this might make a difference."
		
Click to expand...


I think it is hope of the providers. Otherwise it would make updating cpr sort of useless.



firetender said:



			The truth is, on some people it might and others it might kill. Our goal is not to lessen the pain and suffering of our failures, it's to produce an effect in the successes that does just a bit better than sugar pills.
		
Click to expand...


Hopefully a bit more than sugar 



firetender said:



			I believe the poster who said you're butt is more likely to be twisted around since you didn't go into this naive.
		
Click to expand...


Perhaps I was expecting more.*


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## CAOX3 (Oct 30, 2010)

I think healthcare is driven by its customers, if everyone wanted to die gracefully at home it would have gone in a different direction.  People want one more day to spend with their loved ones, to see their children grow up, get married.

Its ultimately their decision, I don't see a problem with that.

We in the the health care field know, we holds are breath when a loved one admits a diagnosis to us, its like a curse sometimes because we know what the eventual out come will be.

We spend are entire lives planning for the future, forming bonds and loving your children, wives mothers and fathers, when a doctor walks through the door and states it isn't going to end like we planned, we as people don't want to accept that so we fight to continue on and that's our choice.  The quality of that life isn't or decision to make, If that's their wish that's what we do.

That's why on scene I try not to think or let my personal opinion s get in the way if their sick and they arrest sure I know the for the most part what the final outcome is going to be but its their choice to spend one day in icu so they can sit with their loved ones, whatever their capacity then we do it, health care is about the patients wishes not the providers.


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## Aidey (Oct 30, 2010)

I don't think the issue is so black and white we can pin the blame on doctors or patients. I think the situation is incredibly more complicated than that, a view which I think is supported by some of the end of life research that has been done. 

With patients things like education, religion, current social life (family, job) all impact the decisions they make. Doctors, as much as no one wants to admit it are also affected by the same things. I read the results of a study recently that showed doctors who identified as religious tended to be more conservative with end of life care. Specifically in the conversations they have and how aggressively they medicate patients with medications that may result in the pt dying sooner, like high dose morphine. 

I know we run into patients who have orders for palliative care, but with CPR. I've been told that this is a common occurrence in some religious patients because they view not doing CPR as hastening death. 

I can also imagine that education levels of the patient play a huge role in how care goes. If a doctor is dealing with a cancer patient from a family where none of them have higher than an 8th grade education. What is easier for the doctor, educating the family and patient to the point they can make informed decisions, or for the doc just to say "this is what we should do" and do it? 

And googling is enough of an issue for its own thread. I'm a huge advocate of education, but when someone becomes convinced that The Internet knows more than any doctor out there there is officially a problem.*

And really, there is always the liability issue. 

Case in point.

Mid 60's male, SNF. Severe cerebral palsy, paperwork states that the pt has the mental status of a toddler. Pt has multiple ongoing medical problems. The pt develops a fever, the staff checks it, gives tylenol and calls the patients guardian to let them know what is going on. The patient's guardianship is through a hired service, he has no next of kin or people to notify on file. The guardian tells the facility to do whatever they think is best. Facility calls 911. 

We get there, the facility is like "yeah we called cause the guardian said we should do whatever". The patient's fever responded to the tylenol, and he is asleep when he get there, not in any apparent distress.The pt has comfort care orders stating no transport unless they have comfort issues that can't be met out of hospital. The patient is in a SNF, and under the care of the facility doctor. The staff have the ability to call the doc or whomever is on call and get orders. 

We talk to the staff, who is ok with the patient staying. We get a hold of the guardian who after being read the patient's advanced directive is ok with the patient staying as long as she isn't the one making the decision (which makes me wonder what the heck good does the patient having a guardian do?). Only thing left is to call med control to sign off on the whole thing. Med control orders transport.

Straight from the doctor's mouth, she was concerned about the liability of not transporting. 

WTF. Seriously WTF. It doesn't make any sense to me. The system was actually working, and she threw a huge wrench in it becuase of concerns about not transporting a patient who had a signed order stating they didn't want transport, and was able to receive completely appropriate care where he was. 

It needs to stop. I swear when I'm old I am having an advanced directive written up that expressly states do not transport, and if you do it will be considered kidnapping. 



*So If you go to the ER for a rash, and the doc checks you out and sends you home, don't call the ambulance 30 minutes later because you think you have the plague thanks to google.


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## Veneficus (Oct 30, 2010)

Aidey said:


> I don't think the issue is so black and white we can pin the blame on doctors or patients. I think the situation is incredibly more complicated than that, a view which I think is supported by some of the end of life research that has been done. .



Here is the problem, in order to pass to the 3rd year of school here, a student must take a palliative care class and clinical. 

But the older physicians have not had it. They are also very set in their ways. Which includes 10's if not 100's of grading and staging charts (everything from COPD to various genetic disorders) and the treatments that go with them.

If the patient is x on scale y, perform such and such treatments. It doesn't require a doctor to do that. Infact I bet I can get any idiot off the street to do it. 



Aidey said:


> With patients things like education, religion, current social life (family, job) all impact the decisions they make. Doctors, as much as no one wants to admit it are also affected by the same things. I read the results of a study recently that showed doctors who identified as religious tended to be more conservative with end of life care. Specifically in the conversations they have and how aggressively they medicate patients with medications that may result in the pt dying sooner, like high dose morphine..



In my opinion physicians who let their religion influence their decisions should lose their license immediately.  There is absolutely no room for imposing arcane values on patients.



Aidey said:


> I know we run into patients who have orders for palliative care, but with CPR. I've been told that this is a common occurrence in some religious patients because they view not doing CPR as hastening death.



I am sorry, I know you are not advocating it, but that sounds absolutely stupid. Religion is the providence of fools. Made for the weak minded. I am afraid to think of what is next.




Aidey said:


> I can also imagine that education levels of the patient play a huge role in how care goes. If a doctor is dealing with a cancer patient from a family where none of them have higher than an 8th grade education. What is easier for the doctor, educating the family and patient to the point they can make informed decisions, or for the doc just to say "this is what we should do" and do it?



I guess it has just been pounded into my head over the last few years that it is the responsibility of the doctor to educate the patients.

The dean of our school often says "many people have medical degrees, few will ever be doctors."

I buy that 100%. Perhaps patients should stop going to see medical scientists. 



Aidey said:


> And googling is enough of an issue for its own thread. I'm a huge advocate of education, but when someone becomes convinced that The Internet knows more than any doctor out there there is officially a problem.*



That is only going to get worse as the time goes on. But it just leads to doctor shopping. Eventually they will find one that gives them what they want. Not really too different from drug seekers really.



Aidey said:


> And really, there is always the liability issue.


 
I think this is a very weak excuse. I also think medical scientists (not to be confused with doctors again) did this to themselves. They created and wrote down the decision trees, the scales, and scores. They basically carved into stone what each patient should receive instead of listing what might be done. 

In the effort to create "evidence" based medicine, medical professionals have basically tied their own hands. If the patient doesn't fit the protocol, they are truly at a loss, they will be put into the protocol and if it doesn't help or actually hurts, everyone will say they played by the book. 

Truly, we should give up educating physicians, we should just develop protocols and give them to lawyers and eliminate the physician entirely. After all, a middleman between the sick and a lawyer really doesn't add any value.


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## MrBrown (Oct 30, 2010)

jrm818 said:


> IPain control...eh...who really cares.  Nice, but they can wait, suffering for 20 minutes isn't that bad, they aren't going to _die_.



Brown hopes you don't treat him, his family or anybody he cares about or does not wish unjustified suffering upon.


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## firetender (Oct 30, 2010)

*Follow the Money!*



Aidey said:


> I think the situation is incredibly more complicated than that....


 
A-(wo)men, Sister

The deeper I get into my own explorations into this, the more I hear these voices in my head, articulating things that the Therapy Manufactureers (without specifying BigPharma, of course!) would say *if they were honest:*

"Well, we came up with *this*. It took care of *that*. In order for *us* to take care of the *other*, we really need *you* to *USE* a lot of _*this.*_ 

Why, you ask?

Because with the money we make by *you* using *this*, (on everyone who falls near the horseshoe pin) we can develop something to combat the *other*, AND build another medical school so we have a lot more of *you* distributing *this* and the other *others* that we come up with. 

Don't worry though, *you* really don't have to sell *us.* We'll take care of that by making sure that *they,* _check_ with *you* to see if ****** can releive them of one of the many niggling symptoms of being alive.

Remember, we're empowering *you* to handle the 44 Magnums, but they're indoor weapons. Outside we make sure *they *buy all the .22s and .38s *they* can shoot at their lower level ailments. See how slickly we've also drawn a line?

Because once someone needs testing to protect *you* and *us* from a lawsuit, *they* come to a box filled with diagnostics created by *us* so *you* have data supporting giving them more of *this* to treat *that*.

See how *IT *works?  If we get them to buy into *us*, *they* go to *you* and we'll *ALL* make a living. Actually, only one of *us* will get rich. *You* will get burned out handling their requests and distributing our goods.

But look at how many people we keep employed; Our financial futures are assured by the endless loop we reflect; pitting hope against hope*.* 

Don't be so selfish!"


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## JJR512 (Oct 30, 2010)

Aidey said:


> ...Med control orders transport.
> 
> Straight from the doctor's mouth, she was concerned about the liability of not transporting.
> 
> WTF.



This is exactly why I added the final paragraph to my most recent reply. Just as it happened to you, I suspect it might happen in that hypothetical scenario you posed.


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