# Stroke patient dies...at shift turnover



## ffemt8978 (Jun 8, 2009)

http://www.telegraph.co.uk/health/h...t-dies-after-ambulance-driver-clocks-off.html

I'm speechless on this one.

I don't think 4 minutes would have made the difference in the patient's outcome, but to clock out in the middle of a transport?  :sad:


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## reaper (Jun 8, 2009)

And they say American EMS is screwed up?


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## bstone (Jun 8, 2009)

It is clearly a violation of human rights to require this driver to work over time.


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## vquintessence (Jun 8, 2009)

Absolutely speechless


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## Tincanfireman (Jun 8, 2009)

Wow...10 char


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## Epi-do (Jun 8, 2009)

That is just completely wrong!  I hope there are plenty of repercussions for that individual.  That being said, I have to agree that the four minute delay most likely did not affect the outcome for this patient.


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## WannaBeFlight (Jun 8, 2009)

OMG!!!!  You have got to be kidding... I am just wondering if the Paramedic in the back knew what he was doing and approved of it, then yes I can see both of them getting suspended. :excl:


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## Burlyskink (Jun 8, 2009)

While I do agree, the 4 minutes probably wouldn't have changed the outcome. The fact that the guy clocked out during a transport amazes me...


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## lightsandsirens5 (Jun 9, 2009)

ffemt8978 said:


> I don't think 4 minutes would have made the difference in the patient's outcome, but to clock out in the middle of a transport?  :sad:



The story seems to say that he was a heart pt. Mebby the 4 mins makes the differnce with that.


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## EMTinNEPA (Jun 9, 2009)

I never switched out during a transport, but I have switched in for people.  We always made the rendezvous at a spot that was between scene and hospital though, we never made detours.


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## downunderwunda (Jun 9, 2009)

Please, lets be realistic. 

They should not have clocked of, but is there more to the story than meets the eye???

It would appear we are making judgments here based on media speculation & we all know that media do not let the facts et in the way of a good story.

There is too much not known to comment ion reallity. Information like was the stroke Ischaemic or Haemhorragic? It does make a difference considering over 90% of Haemhorragic stroke victims die.

Reaper, you said



> And they say American EMS is screwed up?



It is. How many different sets of Protocols are there across each state? Compare that to the UK system. They are pretty uniform across the country. They also do not have issues of Fire tryin to run their EMS system because they recognise it is a profession of its own & should not be lumbered with another.


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## reaper (Jun 9, 2009)

That may be true. Does not matter what the man died from. The issue is the driver changing shifts in the middle of an emergent transport.

Oh BTW, I have never seen that in an American system, in 20 years!


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## downunderwunda (Jun 9, 2009)

Chances are the patient would have died reardless. They use a system similar to ours in the UK, determine the priority of the case, but, as i stated



> They should not have clocked off



however, i am also wondering what the FULL story is. Remember there are 2 sides to every story & to crucify based on one side of the story is inexcusable. The fact they have been suspended is not relevant, we wouldbe automatically suspended here also pending a full investigation. What is interesting however is that this story did not rate a mention on the English association web page new section. 

Lets find the complete picture before we decide who is right & who is wrong. There will be more to this than meets the eye i am sure


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## CAOX3 (Jun 10, 2009)

Hemmorhagic vs ischemic is irrelevent because it cant be determined in the field. The fact that it was a time sensitive condition makes it even more deliquent.  

If in fact it is true, negligence and abandonment seem apropriate punishments.


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## NREMTB12 (Jun 10, 2009)

rather or not the 4 mins would have made a difference, thats not the problem here, ethically this is just wrong, it is not our job to decide whether or not a person will live or die or not, we are to do all that we can do to save their lives, and clocking out in the middle of a shift is in no way fufilling your duty...but that is just me, and about the media, it is what it is...but the core of the message was delivered, nuff said.


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## downunderwunda (Jun 10, 2009)

CAOX3 said:


> Hemmorhagic vs ischemic is irrelevent because it cant be determined in the field. The fact that it was a time sensitive condition makes it even more deliquent.
> 
> If in fact it is true, negligence and abandonment seem apropriate punishments.



Debateable, that is according to our ProQ&A system, it decides that a CVA is to be responded to within an hour.

Oh sorry, did i use the correct term -CVA, maybe, as professionals we should use the proper terminology


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## djmedic913 (Jun 10, 2009)

4 minutes makes a HUGE difference. I know the article was titled Stroke Patient, but the article said possible heart attack.

either way stroke or heart...time is muscle/brain cells...

If they did not divert would the Pt not have coded until they got to the hospital?

Early treatment in either case has shown to prolong death...

we all knew what we were getting ourselves into with this business...I was taught a long time ago, never schedule anything up to 2 hours after my shift.

we get late calls...it happens...I have changed at a scene never delaying Pt care or transport....


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## djmedic913 (Jun 10, 2009)

bstone said:


> It is clearly a violation of human rights to require this driver to work over time.



I hope this was to be sarcastic...

because if this was not sarcasm, then this was one of the dumbest things I have ever heard uttered in EMS...

we don't work 9-5 and we sure as hell don't always get out on time...

we get late calls...it will always happen...and usually happens more when you want to get out on time...


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## djmedic913 (Jun 10, 2009)

OK, 1 more thing about this...

it said they suspended both crew members...

I know as a paramedic I am responsible for everything that goes on with the ambulance, even if I'm in the back. But in the back with a Pt, I can't control what my driver does. The best I can do is yell at them do get me to the hospital. It is not like I can push them out of the driver's seat, coz then I would be abandoning my Pt.

So I'm sure why the attendant was suspended...


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## Bloom-IUEMT (Jun 10, 2009)

downunderwunda said:


> however, i am also wondering what the FULL story is. Remember there are 2 sides to every story & to crucify based on one side of the story is inexcusable. The fact they have been suspended is not relevant, we wouldbe automatically suspended here also pending a full investigation. What is interesting however is that this story did not rate a mention on the English association web page new section.
> 
> Lets find the complete picture before we decide who is right & who is wrong. There will be more to this than meets the eye i am sure




What could possibly be this man's reason for clocking out during a transport?  Maybe if just found out his wife/son/daughter was dying and that moment and he needed to be with them would warrant leaving the pt , but even then its unethical.


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## downunderwunda (Jun 10, 2009)

Bloom-IUEMT,

Selective quotation is an interesting thing, because IF you read my entire post, you would have found I also said



> Quote:
> They should not have clocked off



now I have said it 3 time you might see it was said. 

I do not have the FULL & COMPLETE story. However, you are obviously more informed than I am so play judge, jury & executioner.

djmedic913,

when you said



> 4 minutes makes a HUGE difference. I know the article was titled Stroke Patient, but the article said possible heart attack.



You are right with a heart attack, however, with a CVA (Damn I used the proper term again) the rate of necrosis (damn another proper medical term) & the rate of metabolism (oh no another one) mean that reardless there will be problems, the question is how much damage. 4 minutes is negligable. 2 Hours is important. 2 Hours to determine if it is Haemhorragis or Ischaemic & thrombolyasis (the proper medical terms keep flowing) can take place in a controlled environment. 

But hey, why would we want to consider reality or look at the whole story. I have seen people crucified in te media from a story written on haf (or less) the facts when the reality was completley different. Dont be to quick to judge.

There is one aurentee I will promise you here. If the 2 Officers are found to be negligent by an investigation looking at all of the evidence, it will be fron page news, a huge story, but if they are not found negligent, we will hear nothin more of it. The paper will not publish a retraction, an apology. 

But dont worry uys, you have already made up your minds that they are guilty based on a newspaper report.


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## Scott33 (Jun 11, 2009)

Wanda.

I spend most of my forum time on a UK ambulance site, as that is where I am originally from.

Unfortunately, the general consensus of opinion from some of the UK bods who work with the people involved, seems to be that the events did happen just as reported (not just in the News of the world tabloid rag, but also the BBC news and the broadsheets).  

I can only assume they may have thought the patient was stable enough at the time, to switch crew (perhaps a TIA which had resolved, and before there were any signs of the cardiac event to follow), but all it takes is one moment of shortsightedness to ruin ones career.

Needless to say though, for whatever reason it does appear like they hung themselves out to dry here, and all affected parties will be no doubt be fired. The paramedic, who was the *driver*, will also probably end up losing his HPC registration, and therefor will never be able to work again in that capacity.

Sorry, I have little sympathy for them. Bad, bad judgement and a lesson to us all.


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## ffemt8978 (Jun 11, 2009)

Scott33 said:


> Wanda.
> 
> I spend most of my forum time on a UK ambulance site, as that is where I am originally from.
> 
> ...



So the medic was the driver and the EMT was attending the CVA/cardiac patient?


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## Scott33 (Jun 11, 2009)

ffemt8978 said:


> So the medic was the driver and the EMT was attending the CVA/cardiac patient?



Apparently so.


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## Bloom-IUEMT (Jun 11, 2009)

Calm down Crocodile Dundee-- don't ever say 4 minutes is negligible. Ever. If that's the way you treat your patients I feel sorry for them.  Based on the size and location of the CVA it can make a big difference. And what if it made a small difference?? Wouldn't you want your patient to have the best possible outcome and quality of life?
I'm not making a judgment on those medics because as you say, I don't have all the facts.  But I find hard to believe that any excuse can warrant the actions these particular medics took.  Who knows, maybe I'll be surprised but I doubt it.
And its thrombolysis, not thrombolyasis.  If you are going to be smug about using proper medical terms, be sure they are indeed the proper medical term.


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## rescuepoppy (Jun 11, 2009)

The extra 4 minutes may or may not have made a difference. But the problem for me is that you should not make a detour to your station to clock out just because you are on over-time to find out. I know that a lot of areas are taking efforts to keep over-time to a minimum. However I doubt if management would want an employee to shift change during a transport of this nature to prevent a little over-time. They understand that in this business we can't always stay right up to the minute on when we clock out. I agree with the suspension until they can investigate and sort out all of the details before a final decision is made in the matter.


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## ffemt8978 (Jun 11, 2009)

Bloom-IUEMT said:


> Calm down Crocodile Dundee-- don't ever say 4 minutes is negligible. Ever. If that's the way you treat your patients I feel sorry for them.  Based on the size and location of the CVA it can make a big difference. And what if it made a small difference?? Wouldn't you want your patient to have the best possible outcome and quality of life?
> I'm not making a judgment on those medics because as you say, I don't have all the facts.  But I find hard to believe that any excuse can warrant the actions these particular medics took.  Who knows, maybe I'll be surprised but I doubt it.
> And its thrombolysis, not thrombolyasis.  If you are going to be smug about using proper medical terms, be sure they are indeed the proper medical term.



4 minutes is negligible around here...with hour long transport times to the hospital.  Or, are you suggesting that we need to run code to the hospital for every patient because every second counts? :wacko:

But here's the deal, according to published reports to date, this crew FAILED in two aspects.  1) They detoured to perform a shift change with a deteriorating patient, and 2) The medic was driving and the EMT was performing patient care with said patient.

Would the 4 minutes have made a difference?  We'll never know for sure.  Would the patient be alive if the medic had been attending him instead of the EMT?  Who knows.  You can bet these are the two points that will be hammered on in the subsequent lawsuit, though.


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## Bloom-IUEMT (Jun 12, 2009)

ffemt8978 said:


> 4 minutes is negligible around here...with hour long transport times to the hospital.  Or, are you suggesting that we need to run code to the hospital for every patient because every second counts? :wacko:



For a stroke patient you should always run code 3 or emergent. Doesn't your jurisdiction do that?  Every minute counts when your dealing with infarctions.


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## djmedic913 (Jun 12, 2009)

Bloom-IUEMT said:


> For a stroke patient you should always run code 3 or emergent. Doesn't your jurisdiction do that?  Every minute counts when your dealing with infarctions.



Run hot if you are still under the 3 hr window and depending on the hospital you are taking them to (If they are designated a Stroke Center there is 3, 6, 12 hour window but the regular hospitals it is only a 3 hr window). and if you can't get them to the hospital inside 2 hours of onset, it is not worth running hot...they need about 1 hour get everything set before administering thrombolytics(ie. blood tests, CT scan, etc.)

I agree run hot if you can make the window, but if you can not, there is no need to jeopardize your patient, your crew, or yourself. besides studies have shown driving hot does not save much time over all. (I know the longer the trip the more time saved).


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## zzyzx (Jun 12, 2009)

reaper said:


> That may be true. Does not matter what the man died from. The issue is the driver changing shifts in the middle of an emergent transport.
> 
> Oh BTW, I have never seen that in an American system, in 20 years!



That happened in Minneapolis/St. Paul a year or two ago. It was discussed on this site. Sorry, but I couldn't find the link.


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## downunderwunda (Jun 14, 2009)

Bloom-IUEMT said:


> Calm down Crocodile Dundee.




Before we go any further, I have shown you enough respect to not refer to you as a moronic 20 year old movie character who never has & never will have any relevance to EMS. I have quoted here for you the relevant community rules regarding this.



> we will not tolerate rudeness, defamatory or insulting posts,







> don't ever say 4 minutes is negligible. Ever.



Is this based on the same mentality that still believes the golden hour is real? Firstly, if this is a 'Heart Attack', which one can only assume is Myocardial Ischaemia, then lets be realistic. I would put money on the fact the patient has had some discomfort for well over 60 minutes BEFORE they called you. is another 4 gonna matter?????????? So I arrive, I take their Obs, administer ASA, Nitro get a line started, more nitro, some morphine load & go. I have dilated the vascular bead, thus releaving the ischaemic attack that has been there for 60 mins prior. I transport to hospital, they thrombolyse if indicated, arrange an ICU bed & the patient is managed until a cath lab is available. I have seen pts wait up to 3 months for stenting (which is under review i believe). So what relevance does your 4 minutes have now?

If is was a CVA, then hmmm, again, i bet they didnt call at the immediate point of symptom onset, so again, the time frame is, while critical, not set in stone. If it is haemhorragic, their mortality rate is significantly over 90%, ischaemic, under 30%. Locality of haemhorrage is irrelevant ( 





> Based on the size and location of the CVA it can make a big difference.


) when a patient is coning it is because there is no room in the cranial space. then their mortality is predicted.







> If that's the way you treat your patients I feel sorry for them.




You base this on what? An opinion I have offered in a forum that is cortrary to yours? Mine is based on scientific evidence based practice. Yours is based on what? I have many letters of thanks from patients & their families for the assistance I have offered them, for the honesty I have shown them. I will never lie to a patient or their family, but rather tell it how it is. For that they are greatful. I have to live in a small community where, as a paid professional I am expected to know what I am doing.




> Wouldn't you want your patient to have the best possible outcome and quality of life?



Of course I do, but do i want to shove my head in my *** & think I can save everybody as well? EMS needs to offer patients, families & friends realistic outcomes, nor pipe dreams that will never be realised.



> I'm not making a judgment on those medics because as you say, I don't have all the facts. But I find hard to believe that any excuse can warrant the actions these particular medics took. Who knows, maybe I'll be surprised but I doubt it.



You have made judgment when you said 



> What could possibly be this man's reason for clocking out during a transport? Maybe if just found out his wife/son/daughter was dying and that moment and he needed to be with them would warrant leaving the pt , but even then its unethical.



That is a judgment you have made, without all the facts, without their side of the story. 



> And its thrombolysis, not thrombolyasis. If you are going to be smug about using proper medical terms, be sure they are indeed the proper medical term.



My apologies for having fat fingers, if you take a moment to look at your keyboard, you will notice the A is beside the S, my fat fingers are truly sorry. However, you have missed the point of why i pointed out the fact I used correct terms. I will spell it out for you as you have missed it. I am a medical professional. This is a forum for people involved with EMS & if we want to be taken seriously, treated professionally, then we should start by using the correct terms when we communicate with each other. If you find this too difficult, then we can still use terms that you understand like Heart Attack, Stroke & fit instead of CVA, AMI & Seizure.


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## Bloom-IUEMT (Jun 14, 2009)

downunderwunda said:


> Before we go any further, I have shown you enough respect to not refer to you as a moronic 20 year old movie character who never has & never will have any relevance to EMS. I have quoted here for you the relevant community rules regarding this.
> 
> 
> 
> ...



God, I will *repeat myself: I am not passing judgment on these poor poor blokes I am simply relaying my doubt as to what kind of situation necessitates leaving a CVA or AMI pt while you take a detour to clock out*
That is bad patient care no matter how much you want to rationalize it.  Albeit, it worse to clock out to go the movies than it is to visit a dying loved one, but that still doesn't excuse the bad patient care.  ANd maybe for some reason they did need to clock out at that particular moment...i dont know....Im not saying for sure because I dont know the entire story.  You absolutely right in saying there is two sides to every story.....a man who chops up his family has HIS side of the story to tell as well.  Doesn't mean it excuses the facts.

That is fine you made a mistake typing, and I agree medical terms should be used in place of lay-terms, but there is no reason to be so insolent about your use of them as if you are so elevated in patient care and professionalism that we mere amateurs most defer to your infinite medical knowledge :wacko:

If you want to be so professional and use professional terms, proofread and correct spellings errors.  It seems antithetical to profess wanting to be taken as professional yet misspell , either by purpose or mistake, the medical terms you advocate use of.  

Look, did the four minutes make a difference between his life or death? I don't know.  I *do* know that with a pt having a CVA or AMI time is tissue.  Maybe I am misunderstanding what you are saying but it seems that you are thinking in black and white, live or dead.  My friend there is a whole gray area between the two which is deemed "quality of life."  Your job, my job, our job is to not just get the patient there alive.....its to do what we can to ensure they're best possible post-acute-condition recovery.  "Golden Hour" b.s. aside, the quicker a patient gets to the hospital with a serious acute condition, the better the outcome.  It may not mean the difference between life of death but it may put the patient in better quality of life...and that is why I got into medicine.  I'm not just here to save lives, I'm here to improve lives.

I'm not real good with CNS arterial anatomy so I'll try to illustrate my point best I can-----an artery in right superior parietal lobe anterior to the primary sensory and motor cortex gets occluded and patient presents with some loss of memory and numbness in left face and left arm.  Transport immediately and you better get those thrombolytics in the pt before they lose motor function because the motor cortex is just posterior to sensory cortex (I might have it backwards though^_^ )  The point being a few minutes might be the difference between persistent numbness or having to go through physical therapy.  
Another aspect you are missing is that a pt might not just have one clot.  A minor CVA may be a precursor to a larger CVA.  TIA's are often seem before the onset of large CVAs.  ANd you as EMS don't know that the next clot might occlude the carotid!!  
So irrespective of the said EMS personnel's motive behind detouring to clock out of their shift, it looks bad the patient died.  In reality you are right in saying the 4 min. detour probably didn't matter medically. But in the eyes of family it does, in the eyes of the public it does.  Its just poor reasoning and not the dumbest EMT in our service would do that because in the eyes in of the public, its not professional and its not ethical.


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## Bloom-IUEMT (Jun 14, 2009)

*Another source of story*

http://www.timesonline.co.uk/tol/life_and_style/health/article6452448.ece

Seems driver complained about working overtime and pt was critical.


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## djmedic913 (Jun 14, 2009)

downunderwunda said:


> Is this based on the same mentality that still believes the golden hour is real? Firstly, if this is a 'Heart Attack', which one can only assume is Myocardial Ischaemia, then lets be realistic. I would put money on the fact the patient has had some discomfort for well over 60 minutes BEFORE they called you. is another 4 gonna matter?????????? So I arrive, I take their Obs, administer ASA, Nitro get a line started, more nitro, some morphine load & go. I have dilated the vascular bead, thus releaving the ischaemic attack that has been there for 60 mins prior. I transport to hospital, they thrombolyse if indicated, arrange an ICU bed & the patient is managed until a cath lab is available. I have seen pts wait up to 3 months for stenting (which is under review i believe). So what relevance does your 4 minutes have now?



So, we have established that ischemia will happen before infarction. So you give O2, ASA, Nitro, and Morphine. So you have temporarily delayed the inevitable infarct. I believe we are in agreement here. So with proper medicine and MD management, this may have a chance of surviving with mininal damage to the heart.

BUT if your treatment was withheld for another 4 minutes, depending where the ischemia is, your patient may have coded waiting for you another 4 minutes...


As for the golden hour: It still exists but is not always possible.


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## downunderwunda (Jun 14, 2009)

djmedic913 said:


> As for the golden hour: It still exists but is not always possible.



Do you do all of your pre hospital medical assessments based on marketing principals?

Unfortunatley we cannot teach common sense. Medic Mills will never be able to teach when to stay & play & when to load & go, it comes with experience.



> BUT if your treatment was withheld for another 4 minutes, depending where the ischemia is, your patient may have coded waiting for you another 4 minutes...



Woulda, Shoulda, Coulda. We have to work on what was put in front of us at the time. Instead of saying 





> if your treatment was withheld for another 4 minutes


 try If the patient had called 4 minutes earlier, same outcome.

AMI patients need ICU, we can only delay until we arrive, althoug with the use of pre-hospital thrombolysis, this is improving outcomes continually.


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## downunderwunda (Jun 14, 2009)

> but there is no reason to be so insolent



& calling me Crocodile Dundee isnt?



> Look, did the four minutes make a difference between his life or death? I don't know. I do know that with a pt having a CVA or AMI time is tissue. Maybe I am misunderstanding what you are saying but it seems that you are thinking in black and white, live or dead. My friend there is a whole gray area between the two which is deemed "quality of life." Your job, my job, our job is to not just get the patient there alive.....its to do what we can to ensure they're best possible post-acute-condition recovery. "Golden Hour" b.s. aside, the quicker a patient gets to the hospital with a serious acute condition, the better the outcome. It may not mean the difference between life of death but it may put the patient in better quality of life...and that is why I got into medicine. I'm not just here to save lives, I'm here to improve lives.



I never said it was Black or White, I said we need to be realistic. Do you know the difference between a Haemhooragic CVA & an Ischaemic CVA? I can only presume you are talking Ischaemic CVA because they have excellent recovery rates & the amount of defecit is dependant on eary diagnosis thrombolysis, & properly managed rehabilitation. I would suggest you take a good look at Haemhorragic CVA & then comment the same way. Mortality & Morbidity, even in an ICU is still over 90%. Regarless of time, defecit is nearly alway irreversable & quality of live is minute.



> I'm not real good with CNS arterial anatomy so I'll try to illustrate my point best I can-----an artery in right superior parietal lobe anterior to the primary sensory and motor cortex gets occluded and patient presents with some loss of memory and numbness in left face and left arm. Transport immediately and you better get those thrombolytics in the pt before they lose motor function because the motor cortex is just posterior to sensory cortex (I might have it backwards though ) The point being a few minutes might be the difference between persistent numbness or having to go through physical therapy.



I would suggest you re read what I said. I never suggested delaying more than necesarry, but how many CVA patients will arrive at hospital, & lie on a Hospital bed in an ER for 25, 30 mins waiting for a CT? Where does the 4 minutes fit now?



> Another aspect you are missing is that a pt might not just have one clot. A minor CVA may be a precursor to a larger CVA. TIA's are often seem before the onset of large CVAs. ANd you as EMS don't know that the next clot might occlude the carotid!!



Ah, hello, I do know the difference between a CVA & a TIA. There is only 1 diagnostic tool to tell the difference. 24 hours. Now where is your 4 minutes?



> So irrespective of the said EMS personnel's motive behind detouring to clock out of their shift, it looks bad the patient died. In reality you are right in saying the 4 min. detour probably didn't matter medically. But in the eyes of family it does, in the eyes of the public it does. Its just poor reasoning and not the dumbest EMT in our service would do that because in the eyes in of the public, its not professional and its not ethical.



In reading the further link you posted, he should no longer be employed. 

However, as one comment said 





> To those using this story to bash the NHS - this is a story precisely because it is unusual. It's NOT the norm. You have NO idea of the envy with which people across the world regard the NHS, and you will.be.sorry if the private sector get their claws on the British health industry.



Yes it looks bad. There is no 2 ways about it. He has done wrong. The whole point was to show that un until then, too many people had been Judge, Jury & EZxecutioner without being in full possesion of the facts. 

No EMS system in the world is perfect, this highlights the problem. People do not understand the nature of time in EMS being non existant. However, at least the NHS recognise the value of the work undertaken by their Ambulance Service & pay their employees, not relying on volunteers.


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## Scott33 (Jun 14, 2009)

downunderwunda said:


> at least the NHS recognise the value of the work undertaken by their Ambulance Service & pay their employees, not relying on volunteers.



Whereas I will agree that the NHS have a better system in general, EMS in the UK is no longer a one-man show. The NHS simply could not operate at the scale of which they do, if it were not for volunteers. Specifically CFRs (AKA ORCON clock stoppers), and SJA who have been known to assist with cat C calls in some regions, as well as their event stuff.

Not to mention the many trusts who now have little choice but to contract out some of the lower end IFT jobs, due to demand outweighing supply. 

No system is perfect, and no system is free of the odd irresponsible provider who will come along every so often, and make headline news-worthy errors in their practice. 

Stupidity knows no geographical boundaries.


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## reaper (Jun 14, 2009)

downunderwunda said:


> &
> 
> I would suggest you re read what I said. I never suggested delaying more than necesarry, *but how many CVA patients will arrive at hospital, & lie on a Hospital bed in an ER for 25, 30 mins waiting for a CT?* Where does the 4 minutes fit now?
> 
> ...



Do your hospitals really make them wait 30 minutes for a CT?


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## ffemt8978 (Jun 14, 2009)

reaper said:


> Do your hospitals really make them wait 30 minutes for a CT?



Sometimes...that's how long it takes to call the Radiology crew in from home.  Granted, since our transport times are an hour it's not an issue for us, but some agencies can be at the hospital in less time than it takes for them to call the necessary people in.


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## Scott33 (Jun 14, 2009)

reaper said:


> Do your hospitals really make them wait 30 minutes for a CT?



It does seem a little much. 5 mins or so is the norm in my place if they are showing obvious signs. I have even seen them taken straight from the ambulance stretcher onto CT table. CVA core measures (for those places in which it applies) would not be met with a 30 minute or more wait, so it is as much a reimbursement issue in the US, as it is a practical one. Reimbursement not an issue in other countries.


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## downunderwunda (Jun 14, 2009)

reaper said:


> Do your hospitals really make them wait 30 minutes for a CT?



Depends on what else is in t the same time.

Priority is what comes to the fore. Our transports can be up to & in excess of 1 hour, we call ahead & in most cases, the ER will have made arrangments for radiology, however, I have arrived having done that to see the patient delayed because of a major multi system trauma, who takes precedence when there is only 1 CT available? A 65 YOM with little chance of recovery as he was coning, or a 24 YOM with excellent chances of complete rehabilitation?

As a side note, we did not know he was coning at the time, it was purly on CT it was found, we called it as a CVA based on families reports to us as he was GCS 3 while he was in our care.


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## djmedic913 (Jun 14, 2009)

I understand that there are different levels down under, but I am curious, to what US level would you most closes compare in reference to training and protocols?



downunderwunda said:


> Do you do all of your pre hospital medical assessments based on marketing principals?



I have to ask, Who is marketing the golden hour? Was the golden hour invented by the trauma surgeons to help increase their business and income. A marketing principle? And I always thought is for increase in trauma patient survival rates...guess I was wrong.





			
				downunderwunda said:
			
		

> Where does the 4 minutes fit now?



what happens at the hospital is not our responsibility or concern for the most part. Especially since last time I checked, Doctors are supposed a higher level of care and training than EMS. So what decisions they make for their patients we can not control. Ultimately, our job is to get the patient to the hospital/Dr and hopefully better than we found them (not always possible, I know). The patient does not need to be in the back of our ambulance, but in the hospital with a doctor. Even with all we are now able to do in the back of an ambulance we treat symptoms and never cure anyone. Our jobs are still transportation. As much as we all want to think are jobs are more involved, alas they truly are not. It is our job to transport a patient as safe and fast as possible (this does not always mean driving hot to hospital since driving lights is extremely dangerous).

Back to the original thread for a quick minute. with the new information from the last link, what that medic did was appalling.  the articles make no mention of whether the attendant also left to do crew change or not. If he did NOT, I don't understand why he is in trouble as well.

Whether those 4 minutes contributed to the patient's death is unimportant. What the driver did was unethical, immoral, negligent, abandonment, etc. There is NO excuse or reason for him to do what he did. The idea of family emergency was brought up, and if that was the case or something as horrible, you call your dispatch and get something up. you don't just leave a patient no matter how critical or stable the patient is.


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## ffemt8978 (Jun 14, 2009)

Play nice, everyone.


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## Bloom-IUEMT (Jun 14, 2009)

downundawunda:
...further investigation of the events demonstrates you were wrong and all this hairspliting is going to accomplish is that it's going to make you look self-righteous  in the eyes of your peers.  
I know a lot about CVAs, more than most. And do not think by quoting misplaced statistics that you have proven your point.  The men had *no excuse for what they did* I don't care what the survival rate for hemorrhagic strokes are, I don't care how long the CT wait is. They messed up. THey messed up because they wanted to go home.

90% survival rate huh? What about the 10%? Do they not deserve to rushed to hospital or would your frank honesty tell them "We arent going to rush it mate! THere is a 90% chance your gonna die anyway."  
You are wrong and no matter what you say you will continue to be wrong.  
Are you trying to give *US* an ethics lesson? Are you trying to simply tell us that we shouldn't judge until all the facts are in? Thanks dad, I learned that a looooong time ago.  But as I have alluded to, in this case there could possibly be maybe one reason to clock out and leave a critical patient in the back of the ambulance even that reason is morally dubious.  
That is way we made comments about the medic making the wrong choice. THe argument isn't about whether they were at fault for his death; the argument was whether he should have clocked out and regardless of the outcome he was wrong.
Am I to understand that because you have extended transport times that an extra 4 minutes to stop and have a coke is negligible? Some reasoning skills.

Don't misunderstand, everyone here understands to need to give medics and FF the benefit of the doubt when a sensationalized medic-done-bad article comes out but I believe I have a consensus here when I say this is one of those times there is not much doubt to be raised for this English medic.  Furthermore, am I to understand that because a patient will have wait several minutes for a CT that an extra 4 minutes is meaningless?  Shouldn't that be even more reason to rush the cardiac/cva victim to the hospital?  At some point sir someone has to take accountibility and responsibility of getting the patient to treatment expeditiously.   
My condolences to his family, and my condolences to your future patients. You can tell your next cardiac patient your 4 minutes is negligible theory.


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## downunderwunda (Jun 14, 2009)

djmedic913 said:


> I understand that there are different levels down under, but I am curious, to what US level would you most closes compare in reference to training and protocols?QUOTE]
> 
> Our base level of training is between your EMT-I & EMT-P.
> 
> ...


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## Bloom-IUEMT (Jun 14, 2009)

downunda:
the article you posted was interesting but I believe its referring to trauma pts not medical patients.  Also, he is doubting the exact time the "Golden" should apply to (2 hours? 30 minutes?).  As we are aware, when dealing with CVAs and AMI there definitely is a Golden Something.


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## downunderwunda (Jun 14, 2009)

Bloom-IUEMT said:


> downunda:
> the article you posted was interesting but I believe its referring to trauma pts not medical patients.  Also, he is doubting the exact time the "Golden" should apply to (2 hours? 30 minutes?).  As we are aware, when dealing with CVAs and AMI there definitely is a Golden Something.


I made a veiled reference to the fact you probably believed in it, I did not say that it was relative to medical emergencies.


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## OzAmbo (Jun 14, 2009)

Bloom-IUEMT said:


> For a stroke patient you should always run code 3 or emergent. Doesn't your jurisdiction do that?  Every minute counts when your dealing with infarctions.


No, my jursdiction doesn't do that. In fact id argue that a "jursdiction" that has a system where speed of transport = time saved is negligent and unduly endangerign the public.

I certainly wont bring a CVA in Sig1, there is not point to gain a minute or two that wont change the outcome.

Bloom IUEMT, you had some great info into this, but your starting to come off a bit angry and a tad arrogant. This isn't a lecture in ethics, its a description of downunda's reality, and the reality is that in his situation, mine and many others, 4 minutes is not going to change a thing in the case of a CVA, especially given the amount of variables outside of our control. It doesn't mean we are not time conscious during the length of a case, or condone wasting time by changing drivers or having a coke (i could go a coke now actually) but in downundas reality and in mine, 240 seconds is not going to really alter the outcome. Frequently i pick up patients who started exhibiting AMI or CVA signs hours before hand - I dont condone changing drivers in the middle of a case but i certainly wont run emergent for the sake of making up time, i feel that is an unjustifiable risk to the public for the sake of gaining a couple of minutes.


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## OzAmbo (Jun 14, 2009)

reaper said:


> Do your hospitals really make them wait 30 minutes for a CT?


Naw, not intentionally. But when there is only 1 CT for several hundred kilometers its quite possible to not be the priority for scanning


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## Bloom-IUEMT (Jun 15, 2009)

Well in our jurisdiction, system,county, district, whatever you want to call it we run stroke pts in Code 3 unless the pt began exhibiting sx > 2 hours prior.  
I dont know code 3 means for other folks but for us it doesn't mean running 60mph through a 30 mph zone and running red lights. When a pt is having AMI or CVA we run code 3 and drive with due regard.  
Again, once again, and again: 4 minutes probably doesn't make a big difference but its still a difference and I simply want the best possible outcome for the patient.  That outcome does not come about by taking the stance "a few minutes doesn't matter."  

But idk, I'm a newbie and maybe I'll think differently in the future. Maybe I'm just a idealist.


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## downunderwunda (Jun 15, 2009)

Bloom-IUEMT said:


> downundawunda:
> ...further investigation of the events demonstrates you were wrong and all this hairspliting is going to accomplish is that it's going to make you look self-righteous  in the eyes of your peers.



On the contrary, it has shown the lack of understanding that too many in EMS have



> I know a lot about CVAs, more than most. And do not think by quoting misplaced statistics that you have proven your point.  The men had *no excuse for what they did* I don't care what the survival rate for hemorrhagic strokes are, I don't care how long the CT wait is. They messed up. THey messed up because they wanted to go home.



Um, read my last post, further evidence has come to light. 



> 90% survival rate huh? What about the 10%? Do they not deserve to rushed to hospital or would your frank honesty tell them "We arent going to rush it mate! THere is a 90% chance your gonna die anyway."



I have continually said in my posts that patients deserve the best care, & please quote properly, i said _greater than 90%_ I also believe at one point that I did state that many have severe impairments (i believe i used different terminology) even if this happens in a hospital environment with rehab.




> You are wrong and no matter what you say you will continue to be wrong


.  

In your opinion




> Are you trying to give *US* an ethics lesson? Are you trying to simply tell us that we shouldn't judge until all the facts are in? Thanks dad, I learned that a looooong time ago.



No you didnt, you judged them guilty from the outset.



> But as I have alluded to, in this case there could possibly be maybe one reason to clock out and leave a critical patient in the back of the ambulance even that reason is morally dubious.



If that was the case, why not have a crew meet them en route?



> That is way we made comments about the medic making the wrong choice. THe argument isn't about whether they were at fault for his death; the argument was whether he should have clocked out and regardless of the outcome he was wrong.



Am I to understand you have _NEVER_ made a bad decision? Yes this was a really really bad decision. However djmedic913 made 4 minutes an issue originally. I simply responded to those comments. You decided to run with it.




> Am I to understand that because you have extended transport times that an extra 4 minutes to stop and have a coke is negligible? Some reasoning skills.



Please reread what OzAmbo said, now look at your question again I dont need to respond to this.



> It doesn't mean we are not time conscious during the length of a case, or condone wasting time by changing drivers or having a coke (i could go a coke now actually) but in downundas reality and in mine, 240 seconds is not going to really alter the outcome.





> Don't misunderstand, everyone here understands to need to give medics and FF the benefit of the doubt when a sensationalized medic-done-bad article comes out but I believe I have a consensus here when I say this is one of those times there is not much doubt to be raised for this English medic.



Then why did you not give them the benefit of the doubt in the first instance?



> Furthermore, am I to understand that because a patient will have wait several minutes for a CT that an extra 4 minutes is meaningless?



Umm, who said that? Both OzAmbo & myself have both said that we do not condone wasting time on scene, I know I have never said it, in fact I know I said we should do the opposite & aviod wasting time on scene.



> Shouldn't that be even more reason to rush the cardiac/cva victim to the hospital?



Pre hospital medicine is moving forward, Evidence Based Practice has *proven* that early reperfusion of the myocardium is vital to ensure an positive outcome for the patient. While I do not waste time on scene, I will usually be there 10-15 minutes allowing for some drug administration, that is proven to assist with said reperfusion, gaining IV access, allowing my partner time to organise egress, & administration of IV morphine. 

Answer me this, what is better for the patient, to have 2 EMT's who have the knowledge of what is happening, what to do that remain calm, drive appropriatly to the hospital without further causing tension to the patient, or one who will rush rush rush causing further panic & increasing myocardial excitment?



> At some point sir someone has to take accountibility and responsibility of getting the patient to treatment expeditiously.



I am accountable to my patients, who are also members of the community in which I live. I am responsible for my action to my employer & regulatory body. We have targets which, with the odd excedption due to access or patient size issues, that are met. 




> My condolences to his family, and my condolences to your future patients.



You are basing this judgment on what? Have you ever seen me treat a patient? Have you seen me control a scene? You claim to have more knowledge than most on CVA's yet you are ignorant to other opinions & reasoning that differs from yours in any way. 



> You can tell your next cardiac patient your 4 minutes is negligible theory



My next cardiac patient will receive the best treatment I can offer, as all have done in the past. I look forward to the completion of thrombolysis trials & the roll out of thrombolytics to allow us greater lattitude & transport options. 

My advice to you is read, reread & learn from what people are saying. You may one day make a good EMT. Face reality, stop being abusive to those who may have a greater knowledge than you do.


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## Bloom-IUEMT (Jun 15, 2009)

downunderwunda said:


> I have continually said in my posts that patients deserve the best care, & please quote properly, i said _greater than 90%_ I also believe at one point that I did state that many have severe impairments (i believe i used different terminology) even if this happens in a hospital environment with rehab.



Excuse me, greater than 90%! The only percent that would make a difference is 100%. Then we can say transport time doesn't matter. 



downunderwunda said:


> In your opinion



No, follow up on the story please.  The medic clocked out because he wanted to go home...its in black and white. You wanted to defend his actions and you were wrong. Its ok, it doesn't make you bad person, it doesn't make me a good EMT. Its noble of you to want to stand up for colleagues but I think you're aware that just because we have the same job doesn't mean I hold to a lower ethical standard.  Defending someone based on the fact you wear the same uniform is what we call the "good ole boy system" here in America.  Its abhorrent.



downunderwunda said:


> No you didnt, you judged them guilty from the outset.





Bloom-IUEMT said:


> What could possibly be this man's reason for clocking out during a transport?  Maybe if just found out his wife/son/daughter was dying and that moment and he needed to be with them would warrant leaving the pt , but even then its unethical.



Yeah it really sounds like I am nailing them to a cross doesn't it




downunderwunda said:


> If that was the case, why not have a crew meet them en route?


 
Would have made more sense.



downunderwunda said:


> Am I to understand you have _NEVER_ made a bad decision? Yes this was a really really bad decision. However djmedic913 made 4 minutes an issue originally. I simply responded to those comments. You decided to run with it.



There is a difference between making a bad decision during a tense moment that turns out to wrong than doing something unethical because you feel you are entitled.  




downunderwunda said:


> Then why did you not give them the benefit of the doubt in the first instance?


 
See above



downunderwunda said:


> Umm, who said that? Both OzAmbo & myself have both said that we do not condone wasting time on scene, I know I have never said it, in fact I know I said we should do the opposite & aviod wasting time on scene.



Them why make excuses for the English Medic if you don't condone it?



downunderwunda said:


> Pre hospital medicine is moving forward, Evidence Based Practice has *proven* that early reperfusion of the myocardium is vital to ensure an positive outcome for the patient. While I do not waste time on scene, I will usually be there 10-15 minutes allowing for some drug administration, that is proven to assist with said reperfusion, gaining IV access, allowing my partner time to organise egress, & administration of IV morphine.



Amen. I don't consider giving IV cardiac drugs wasting time so I'm not sure why you are even bringing this up. 



downunderwunda said:


> Answer me this, what is better for the patient, to have 2 EMT's who have the knowledge of what is happening, what to do that remain calm, drive appropriatly to the hospital without further causing tension to the patient, or one who will rush rush rush causing further panic & increasing myocardial excitment?



Just because you're driving code 3 doesn't mean your being reckless, I can drive appropriately to the hospital and get there fast on code 3. believe me when I say at our EMS safe driving is beaten into our heads and engraved in our skin.  




downunderwunda said:


> You are basing this judgment on what? Have you ever seen me treat a patient? Have you seen me control a scene? You claim to have more knowledge than most on CVA's yet you are ignorant to other opinions & reasoning that differs from yours in any way.



I'm ignorant because why? I don't agree with you? I beg to differ.  I'm pretty sure you said if the patient was having a hemorrhagic CVA as oppose to ischemic CVA then the 4 minute hold over wouldn't be as bad.  Regardless if it was ICVA or HCVA the medic did not know and had a duty to transport immediately. 



downunderwunda said:


> My next cardiac patient will receive the best treatment I can offer, as all have done in the past. I look forward to the completion of thrombolysis trials & the roll out of thrombolytics to allow us greater lattitude & transport options.
> 
> My advice to you is read, reread & learn from what people are saying. You may one day make a good EMT. Face reality, stop being abusive to those who may have a greater knowledge than you do.



I see, because I am new and you have many years experience I can't argue patient care ethics or about CVA patients.  Although i am new to EMS a big problem I can see a few paramedics think they can do no wrong, not a good way to grow as a person or a professional. 
I am agreeing that a few minutes doesn't make a big difference---it still makes A difference and that difference will have to experienced by the patient, not you.  We both agree that we want the best possible outcome for our patients so why do you disagree that a few minutes of infarction matters to the patient.  It makes a measurable difference and if I can save some tissue by running emergent, then will....of course with regard to the safety of me, my pt. and the general public.  
I have no doubt you are an excellent medic and your patients get the best care you can give them...and....well.....thats it...thought I'd end with a compliment.


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## ffemt8978 (Jun 15, 2009)

Okay, I don't see anything good coming from this little 
	

	
	
		
		

		
			




so the thread is now


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