# Paramedic Incompetence Question



## AMF (Dec 5, 2011)

Background:
    I work for a QRS, meaning we don't transport.  When we get dispatched, the neighboring ALS service, which usually runs double paramedic, gets dispatched as well.  This service is one of the best in North America; I did my basic ride time with them and have nothing but the utmost respect for them.

Scenario:
    I'm running secondary on a call for an intox male in need of evaluation.  We get there and the scene is covered in urine (the entire dorm room).  Security found the patient in "kowtow" and brought him up against the bed (violating c-spine) to try to wake him before we got there.  Bystanders report that the patient was found in the "kowtow" position by his bed, 3' to 4' feet off the ground.  Patient presents with a laceration on his forehead several cm in diameter.  He is A&Ox0 with a GCS of 9 (5 Motor, barely; 2 Vocal, barely; 2 Pupilary, but fighting it) and has bilateral but slow reaction of pupils to light.
    Paramedics get on scene as we discuss boarding him.  The primary paramedic is apathetic ("sure, whatever") but insists that he's not carrying the patient.

Question:
    I know he's in the wrong about boarding him; I'm not really asking about that.  But my partner then says, in essence, "Obviously you out rank us, but we'd really like to board him."  Is that true?  I've always treated the paramedics as ALS intercepts.  They're not part of our service, so the patient isn't theirs until we transfer care.  

To reiterate, nothing against paramedics.  Most of the ones I interact with are PIFTs with college degrees.  They are well-experienced and use expensive procedures sparingly and don't mess up.


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## Handsome Robb (Dec 5, 2011)

I'm not sure if I understand the question. Are you asking if it was appropriate to question the medic or if it is you're patient until you hand them off?

As long as the question is worded tactfully I don't see any reason why it would be inappropriate. 

As for whose patient they are once ALS is on scene he is "theirs" so to speak. The medic on scene is the medical authority and ultimately responsible for care of the patient. If they don't want to board him they don't have to. Document it in your chart along with the efforts you made to argue your case to them.

Personally I'd be on the fence for boarding this patient but at this point you're going to be bound by protocol.


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## AMF (Dec 5, 2011)

Why would you be on the fence?  He has a questionably significant mechanism of injury to the cervical spine and is incompetent.  In Maine, that means he can't be ruled out of spinal immobilization.  What would you consider the baseline indication for spinal immobilization?

So we could/have to just leave the patient with them?


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## Shishkabob (Dec 5, 2011)

I'll preface this post with saying follow your agencies guidelines.




Then I'll say once the Paramedic has made patient contact, it's 'their' patient until they say otherwise.


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## the_negro_puppy (Dec 5, 2011)

AMF said:


> Why would you be on the fence?  He has a questionably significant mechanism of injury to the cervical spine and is incompetent.  In Maine, that means he can't be ruled out of spinal immobilisation.  What would you consider the baseline indication for spinal immobilisation?
> 
> So we could/have to just leave the patient with them?



What is the Kow Tow position?

It is a judgement call about c-spine. Sure you could board and collar him, on the extremely slim chance he has a c-spine or other spinal injury. Once he starts vomiting he is going to be much more difficult to manage, let alone if he tolerates being immobilised.

But to err on the side of caution if he is ALOC, with a mechanism present and unable to be properly assessed due to intox, immobilising would be the safer route.

Don't forget that airway takes precedence over c-spine. If the security left him in an awkward position and he starts vomiting, then what?


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## Handsome Robb (Dec 5, 2011)

I don't know your SOPs or protocols that cover your interactions with them so I won't/can't give you advice on that one, sorry. What I will say is with no transport capabilities you don't have much of a choice now do you?

He really doesn't have a significant MOI, a 3 foot fall is not significant. If we boarded and collared every single drunk who took a digger we wouldn't have enough c-spine gear after a couple hours on certain shifts where I work. I'll go a step further and ask if you if you'd board every Nana who fell down and bumped her head?


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## Shishkabob (Dec 5, 2011)

And while I'm not a fan of it... an altered (and potentially drunk) patient, with a head injury will be getting a backboard and c-collar from me.


I have yet to see field clearance protocols from any agency that let's you withhold a backboard from an altered head injury patient short of fighting them on.


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## lightsandsirens5 (Dec 5, 2011)

Linuss said:


> I'll preface this post with saying follow your agencies guidelines.
> 
> 
> 
> ...



Second that.

I even operated under that principle when I was working as in Intermediate. If I "wanted" a patient from a basic, I took over, regardless of weather they were "ready" to transfer care. I see it as "Me: Higher level of care...therefore...my call...therefore...my scene and my patient."


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## Shishkabob (Dec 5, 2011)

lightsandsirens5 said:


> "Me: Higher level of care...therefore...my call...therefore...my scene and my patient."



"Therefor, my certification on the line if something goes wrong, therefor my job, therefor my livelihood."


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## Handsome Robb (Dec 5, 2011)

Linuss said:


> And while I'm not a fan of it... an altered (and potentially drunk) patient, with a head injury will be getting a backboard and c-collar from me.
> 
> 
> I have yet to see field clearance protocols from any agency that let's you withhold a backboard from an altered head injury patient short of fighting them on.



I will agree with this from a CYA standpoint, but I'm with you I really don't like it.


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## Aidey (Dec 5, 2011)

Are we assuming he fell off the bed?


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## Handsome Robb (Dec 5, 2011)

Aidey said:


> Are we assuming he fell off the bed?



I think that's where this is headed.


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## Sasha (Dec 5, 2011)

I'm seriously getting into the mind set, you want to make the treatment calls then go to medic school. 

word questions nicely and politely but accept the fact you're not in charge.


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## mycrofft (Dec 5, 2011)

*What is this "kowtow" position?*

If it is on haunches but chest and face are in the rug, how can that be 3-4 feet off thee floor?

Parse and 5=4, follow protocols. Try not to kneel in the urine.


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## AMF (Dec 5, 2011)

lightsandsirens5 said:


> Second that.
> 
> I even operated under that principle when I was working as in Intermediate. If I "wanted" a patient from a basic, I took over, regardless of weather they were "ready" to transfer care. I see it as "Me: Higher level of care...therefore...my call...therefore...my scene and my patient."



If I respond to a scene as a primary only the patient's physician, my super, and my medical director outrank me.  In general, I wouldn't take over a scene until I got a report.  Especially if I was giving medication (I don't know if intermediates do that in your jurisdiction).


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## AMF (Dec 5, 2011)

mycrofft said:


> If it is on haunches but chest and face are in the rug, how can that be 3-4 feet off thee floor?
> 
> Parse and 5=4, follow protocols. Try not to kneel in the urine.



How do you board someone without kneeling (It filled the room)?

Protocol says:
Uncertain Mechanism of injury?
Acute Stress Reaction ---------> Board
Tenderness or pain on spine --> Board
CMS F'n Test failure -----------> Board
Basic Stroke Test failure ------> Board
Unreliable Patient --------------> Board
Else -----------------------------> Don't Board

He definitely fell.  Bystanders (reliable) said he didn't have the laceration/contusion earlier that night.  And him being combative wasn't a problem.  He could barely keep his eyes open.  

I agree that airway is a greater priority.  If I were an ALS provider I would have used a blind airway.  As it was, I was considering an OPA (but I was just the secondary).  

I don't see how his fall wasn't at least questionably significant.  He fell 4' on his head.


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## AMF (Dec 5, 2011)

NVRob said:


> I don't know your SOPs or protocols that cover your interactions with them so I won't/can't give you advice on that one, sorry. What I will say is with no transport capabilities you don't have much of a choice now do you?
> 
> He really doesn't have a significant MOI, a 3 foot fall is not significant. If we boarded and collared every single drunk who took a digger we wouldn't have enough c-spine gear after a couple hours on certain shifts where I work. I'll go a step further and ask if you if you'd board every Nana who fell down and bumped her head?



I think that was the paramedic's attitude.  My thoughts, which you are free to disagree with: If you only get a couple hours off, you only get a couple hours off.


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## JPINFV (Dec 5, 2011)

AMF said:


> I think that was the paramedic's attitude.  My thoughts, which you are free to disagree with: If you only get a couple hours off, you only get a couple hours off.



What do you mean by a couple hours off? As in down time? As in people who don't c-spine don't do it because they're lazy?


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## AMF (Dec 5, 2011)

JPINFV said:


> What do you mean by a couple hours off? As in down time? As in people who don't c-spine don't do it because they're lazy?



I think that was what the paramedic was thinking.  I misread NVRob's post; he seems to be talking about a supply issue, which is not the issue here.  It's our board anyways.

I would again ask: what is the baseline indication at your company/region/whoever sets your protocols for spinal immobilization?


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## Akulahawk (Dec 5, 2011)

AMF said:


> How do you board someone without kneeling (It filled the room)?
> 
> Protocol says:
> Uncertain Mechanism of injury?
> ...


IMHO, the answer is simple. You follow your protocols. If the primary decides not to follow protocol, you document it and let the primary take the consequences. If this patient can't protect his own airway, I'd consider intubation as well, but I'd want to use an actual ETT instead of a KT, Combitube, or LMA. If you think that the patient needs that advanced airway, doing an airway assessment might be a BIG priority... 

When I as a paramedic, arrive on-scene, normally I want to get to the report and begin my  assessment immediately.  If a lower level provider does not want to give up care and I think the patient can benefit from a paramedic, I will take over.  That could mean calling law enforcement to have that lower level provider ejected from my scene. Now if a lower level provider is appropriate to provide care, I will do my assessment and triage the patient back to the lower level provider.  My documentation will reflect that. 

If that lower level provider does not want to take care back from me, I am stuck with the patient. 

There are very few times that I would steam roll over another provider.  And there are very few times that I've ever had to do it.  Those times that I have, it has always been a lower level provider that was not providing appropriate care.

If the other provider is at the same level as I am, I  have to get medical control online to provide guidance.  Fortunately have never had to do that.


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## AMF (Dec 5, 2011)

Akulahawk said:


> IMHO, the answer is simple. You follow your protocols. If the primary decides not to follow protocol, you document it and let the primary take the consequences. If this patient can't protect his own airway, I'd consider intubation as well, but I'd want to use an actual ETT instead of a KT, Combitube, or LMA. If you think that the patient needs that advanced airway, doing an airway assessment might be a BIG priority...
> 
> When I as a paramedic, arrive on-scene, normally I want to get to the report and begin my  assessment immediately.  If a lower level provider does not want to give up care and I think the patient can benefit from a paramedic, I will take over.  That could mean calling law enforcement to have that lower level provider ejected from my scene. Now if a lower level provider is appropriate to provide care, I will do my assessment and triage the patient back to the lower level provider.  My documentation will reflect that.
> 
> ...



Re: scene control, that answers some questions.  Thanks.

Re: Airway, I'm not a paramedic.  ETI is a paramedic-only skill.  I rode with the patient, but they ran the call bls code 1.  The paramedic didn't even report the lack of responsiveness until after he called in.  Obviously, as an EMT student, I've been taught only the worse-case scenarios, which is why I'm asking: what is the least that could happen to warrant spinal immob at your companies?


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## Aidey (Dec 5, 2011)

AMF said:


> How do you board someone without kneeling (It filled the room)?
> 
> Protocol says:
> Uncertain Mechanism of injury?
> ...




Um, what?


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## Handsome Robb (Dec 6, 2011)

AMF said:


> I think that was what the paramedic was thinking.  I misread NVRob's post; he seems to be talking about a supply issue, which is not the issue here.  It's our board anyways.
> 
> I would again ask: what is the baseline indication at your company/region/whoever sets your protocols for spinal immobilization?



I'm not lazy if that's what your implying. Also, we have plenty of supplies, the problem is taking units OOS to restock if every drunk person gets spinal motion restriction, which by the way is what we do, we don't provide spinal immobilization.



> • Full spinal motion restriction should be provided for all patients who:
> o Have midline cervical or thoracolumbar spinal tenderness or pain, pain
> with gentle palpation, distal numbness, tingling, weakness or
> paralysis, all with appropriate traumatic mechanism
> ...



There ya go. Our medical director also allows us to use our judgment to make decisions.


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## systemet (Dec 6, 2011)

I'm not sure I'd be rushing to RSI this guy based on the information given.  Obviously we need a bG.  If they're oxygenating / ventilating ok, and they're maintaining the airway, I think we can wait on that.  Just an opinion --- it's always hard to get a decent impression of how the patient presented from a brief description on-line.

I think the issue here is whether c-spine is indicated.  And that rests on whether you feel you have a positive mechanism or not.  It's a little hard to know in this situation, and I think even as a medic, with an unknown mechanism, altered LOC and obvious facial trauma, I'd be pretty keen to board this guy, even if I suspect the probability of an unstable fracture is pretty ridiculously low.  

If you believe there's a mechanism, neither NEXUS nor Canadian C-spine rule can be applied.  If you feel comfortable saying there's no mechanism, then you can avoid the whole issue.  Being honest, I think we could probably avoid boarding most of these patients without missing too many fractures.  And most of the fractures we miss will likely be stable, or the damage already done.  But I don't think most of us are willing to take the risk, or accept the potential liability.  Sometimes it's easier to over-treat in this situation.

Of course, it's not the same everywhere.  Just in randomly travelling around Europe I've seen two patients I would have c-spine'd, that the local EMS crews haven't been concerned about.  One guy got hit by a seadoo, fractured jaw, spitting up teeth, brief period of unconsciousness / apnea, but GCS 14 after having been removed to dry land.  No c-spine applied.  Another guy who took a header off a bicycle at a fair speed, suturable laceration and decent hematoma minutes afterwards, with confusion and true repetitive questioning, same decision.  Not what I'm used to --- but c-spine practices vary in EMS systems across the world.


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## Veneficus (Dec 6, 2011)

*I absolutely hate spine boards...*



AMF said:


> Background:
> I work for a QRS, meaning we don't transport.  When we get dispatched, the neighboring ALS service, which usually runs double paramedic, gets dispatched as well.  This service is one of the best in North America; I did my basic ride time with them and have nothing but the utmost respect for them..



I love this, it is like saying "my friend is (race x)" before telling a racial joke.




AMF said:


> I'm running secondary on a call for an intox male in need of evaluation.  We get there and the scene is covered in urine (the entire dorm room).  Security found the patient in "kowtow" and brought him up against the bed (violating c-spine)..




What kind of violation is c-spine? Felony?  Bad touch? 




AMF said:


> to try to wake him before we got there.  Bystanders report that the patient was found in the "kowtow" position by his bed



Please, when discussing medicine or medical care with a group of international participants, the internationally accepted medical terminology is generally helpful.



AMF said:


> 3' to 4' feet off the ground.



Aka, not far if he fell at all. 

Also, kids and drunks have this amazing, bouncing, injury avoidance capability.



AMF said:


> Patient presents with a laceration on his forehead several cm in diameter.



Diameter? It was circular? Or simply a straight laceration? Exactly how long was it? Was it bleeding? What kind? How much?




AMF said:


> He is A&Ox0 with a GCS of 9 (5 Motor, barely; 2 Vocal, barely; *2 Pupilary, but fighting it*



Forgive me, but what does this mean? 





AMF said:


> Paramedics get on scene as we discuss boarding him.  The primary paramedic is apathetic ("sure, whatever") but insists that he's not carrying the patient.



I am not surprised.




AMF said:


> I know he's in the wrong about boarding him; I'm not really asking about that.



Do you really think so?

Perhaps you may consider the reason your (and most EMT-B) protocols on immobilization are:

1. outdated
2. put in place because basic level providers largely do have the education to decide when to use or not use (allow me to be generous) spinal motion restriction?

In fact, even outside EMS, most low positions which require such low level training do not allow much decision making. 





AMF said:


> But my partner then says, in essence, "Obviously you out rank us, but we'd really like to board him."  Is that true?  I've always treated the paramedics as ALS intercepts.  They're not part of our service, so the patient isn't theirs until we transfer care.



I think you are getting too hung up on the whole "rank" thing.

Patient care is not always about rank. It is about doing what is best for the patient.

Every drunk person who falls down and goes boom does not require a backboard. If the guy was 6 feet tall and fell from standing his head would have traveled farther. 

Incidentally, what exactly was the mechanism of c-spine injury you were considering? Flexion? Extenstion? Rotation? Lateral compression? Hyperextension?

What would cause each of those mechanisms?

Do you think that the foreces were serious enough not only to fracture the body of a vertabrae (not just a spinus or transverse process) as well as damage the muscles and other soft tissue suporting the spine, beyond their ability to do so?

Do you think there was direct spinal cord insult or perhaps ischemia due to compartment restriction of of inflammation?

If the latter, do you think putting a ridgid device that restricts compartment expansion would help?

Rules are more like guidlines and some level of rational sense needs to be applied.

In the absence of the ability to make decisions, you follow your rules not because they are best, but because you have no other option. People who are not bound by such rules are not incompetent.




AMF said:


> To reiterate, nothing against paramedics.  Most of the ones I interact with are PIFTs with college degrees.  They are well-experienced and use expensive procedures sparingly *and don't mess up*.



:rofl:

Who are these masked gods of medicine?

Everyone messes up, it is part of being a human being. The real trick is to minimize it and recover when you do.

Onto this airway thing I read snippits of...

Did somebody suggest an ET or combitube? For what?

I also recall mention of an OPA. given the patient was sitting up and still breathing at one point, an NPA might be a better idea.

Guys (and gals) please. Not every patient is in critical condition. Most of them are not. If you got drunk at a party and fell off of a bed, do you really think the solution is to be strapped to a backboard and have a plastic tube stuck in your throat? "just in case?"

I guess pressure sores don't mean much to you, nor aspiration or foreign body obstruction.

When that patient is tied down on their back, do you really think you can manage their airway and stop them from aspirating vomit, Because you will have to be really quick to turn that board on its side before you see the vomit and a patient takes another breath. 

I can offer my assurance if your service goes around thinking RSI and a tube is the proper solution to every drunk who might vomit, you won't be doing RSI much longer for a number of reasons.

If we consider the next step, which is the ED, what about the cost  of your CT to clear your spine? 

How many beds does your hospital have to babysit drunks all night?

How many drunks do you have that would going to those hospitals in any given night?

Have you ever heard of this?

http://en.wikipedia.org/wiki/Dunning-Kruger_effect

I am not trying to be a jerk, but you seem kind of new. So rather than get into a rant or discussion on who is right or wrong, perhaps a better question would be "why" did any given actions, treatments, etc occur or not occur?

Granted, something are right or wrong. But they are few.


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## DrankTheKoolaid (Dec 6, 2011)

*re*

This pretty much negates any further discussion.  

http://wishididntknow.com/2011/11/1...f-4-foot-high-dorm-bed-paralyzed-sues-school/

Like it or not protocols are there for a reason, an altered ETOH+ patient is NOT a good historian and needs to be placed in full spinal precautions.


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## hippocratical (Dec 6, 2011)

*Veneficus*, that was an impressive smackdown of a reply, and while I agree with much of it, I'm sure others are going to get pissed about it.

On a separate note though:


Veneficus said:


> http://en.wikipedia.org/wiki/Dunning-Kruger_effect



That's pretty awesome. I wondered why I hadn't heard of this (as a Psych major myself) but it seems it was published just after I graduated. I especially like this tidbit though:

_"Dunning and Kruger were awarded the 2000 Ig Nobel Prize in Psychology for their report, "Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments"_

How I would love to have been awarded an Ig Nobel! It's a fantastic ceremony I hear...

[EDIT] Oh and I love this bit:

*it is clear from Dunning's and others' work that many Americans, at least sometimes and under some conditions, have a tendency to inflate their worth.*

;-)


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## JPINFV (Dec 6, 2011)

Corky said:


> This pretty much negates any further discussion.
> 
> http://wishididntknow.com/2011/11/1...f-4-foot-high-dorm-bed-paralyzed-sues-school/
> 
> Like it or not protocols are there for a reason, an altered ETOH+ patient is NOT a good historian and needs to be placed in full spinal precautions.




Call me when a verdict comes back.


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## DrankTheKoolaid (Dec 6, 2011)

*re*

No verdict needed, this shows exactly why these protocols are in place.  Though this type of incident is certainly the exception and not the rule, it is why protocols are in place.  

Verdict? What verdict if the family wanted to sue EMS it would have been cut and dry?  If their protocols say +ETOH is an inclusion into the spinal immobilization algorithm then it is a cut and dry case.  They did not follow well established and universally accepted protocols and the patient may have been placed in further harm because of it.  But It appears they went after the bigger pockets and went after the institution instead.   But the point is the same, Think if was YOUR company employee that failed to care for this person per protocol and had a poor outcome like this possibly worsened by that crews negligence..........

From a risk management stand point, if it was a paid employee they would be hung out to dry by our own insurance and would be left to defend themselves and be both financially and legally responsible.  And heaven help ya if you did not have you own malpractice policy.


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## mycrofft (Dec 6, 2011)

*To clarify my little reply*

What is a kowtow position? I finally understood, the *bed* is about 4 ft off the ground (same as that one in the news article), not the kowtow position.
As for not kneeling in urine, stay off your knees, just like when brains or feces are scattered about. Or broken glass. Or drag a blanket or pillow down and use that.
Still and all, follow for protocols unless there is an overriding necessity they don't cover. Including pecking order.


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## JPINFV (Dec 6, 2011)

Corky said:


> No verdict needed, this shows exactly why these protocols are in place.  Though this type of incident is certainly the exception and not the rule, it is why protocols are in place.


You're telling me that if he wouldn't have followed protocols then he wouldn't be sued?

As far as protocols in place, are you suggesting that protocols should be followed like a cookbook without thought by the individual providers? 



> Verdict? What verdict if the family wanted to sue EMS it would have been cut and dry?  If their protocols say +ETOH is an inclusion into the spinal immobilization algorithm then it is a cut and dry case.  They did not follow well established and universally accepted protocols and the patient may have been placed in further harm because of it.  But It appears they went after the bigger pockets and went after the institution instead.   But the point is the same, Think if was YOUR company employee that failed to care for this person per protocol and had a poor outcome like this possibly worsened by that crews negligence..........



Everything is situationally dependent. I can easily think up specifics in a case like this where not immobilizing the patient would be completely justified. This is ignoring, of course, the fact that spinal immobilization has absolutely zero evidence supporting it. It's akin to modern day blood letting. 

Besides, you're still missing proximate cause. Prove that the lack of immobilization is what caused the damage? How often do you see patients laying in the ER on a spine board who *has* been worked up?




> From a risk management stand point, if it was a paid employee they would be hung out to dry by our own insurance and would be left to defend themselves and be both financially and legally responsible.  And heaven help ya if you did not have you own malpractice policy.


What's the purpose of having malpractice insurance if you're just going to cut employees loose if they are sued?


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## Veneficus (Dec 6, 2011)

Corky said:


> No verdict needed, this shows exactly why these protocols are in place.  Though this type of incident is certainly the exception and not the rule, it is why protocols are in place.
> 
> Verdict? What verdict if the family wanted to sue EMS it would have been cut and dry?  If their protocols say +ETOH is an inclusion into the spinal immobilization algorithm then it is a cut and dry case.  They did not follow well established and universally accepted protocols and the patient may have been placed in further harm because of it.  But It appears they went after the bigger pockets and went after the institution instead.   But the point is the same, Think if was YOUR company employee that failed to care for this person per protocol and had a poor outcome like this possibly worsened by that crews negligence..........
> 
> From a risk management stand point, if it was a paid employee they would be hung out to dry by our own insurance and would be left to defend themselves and be both financially and legally responsible.  And heaven help ya if you did not have you own malpractice policy.



You know what that lawsuit looks like? 

Desperation.

The kid was stupid and wants somebody else to pay for it.

Suing the school for not putting handrails on a bed in a college dorm?

I doubt even the OJ jury will swallow that one.

I want to see how they prove the actions of the EMTs resulted in the actual harm or loss and not the initial strike.

I would like to see the expert witness explain how they could tell the difference from the damage caused by the fall, the alcohol intox, and the actions of the EMS persons.

I also didn't see what the "reasonable attorney fees" are or if it is Pro Bono (which i somehow doubt)

As well, how many lawyers do you think would waste time suing somebody who makes at or near minimum wage.

If the defense got a seperation of the university from the EMS volunteers, I'll bet that suit would be dropped. Dewey, Cheatum, and Howe really doesn't want 33% of nothing. Just like they wouldn't want 33% of the $8 an hour the pro EMT makes.

This kid is messed up only because his parents didn't teach him to act responsibly. 

If he is under 21 (or the local drinking age) his case is probably already over. I am sure most states have laws against seeking damages while engaged in the commiting a crime. 

It sounds to me like the lawyer just wants a quick cash settlement, Which will come nowhere near the charity medical costs, because I doubt very much the doctors and facilities treating him think they ever will actually recoup the costs, much less the bill.

And imagine the argument I would formulate if I was a lawyer.

You cannot eliminate the threat of being sued, it is pointless to try, and more pointless to think inducing panic (a crime) over it will change anything.

Verdicts count.


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## mycrofft (Dec 6, 2011)

*It IS this incident, isn't it?*

http://emtlife.com/showthread.php?p=357613#post357613


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## DrankTheKoolaid (Dec 6, 2011)

*re*

Your missing my whole point.  Do you think these EMS outfits have endless funds and lawyers on retainer? I think not.  

Train your people to follow protocols as given by your medical director.  Any variance from protocols why would a company waste valuable resources defending them when they have simply become a liability. 

And no, I do not believe in cookie cutter blindly following protocols either.  But time and time again altered and ETOH+ patients have proven to be poor historians and unreliable on exam.  These cases both show it.  

And your right the kid did the damage himself and EMS is really not to blame.  But when something like this goes up in front of a bleeding heart jury anything can happen....................


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## JPINFV (Dec 6, 2011)

I think you overestimate the ability of protocols to protect you from lawsuits. 



> Any variance from protocols why would a company waste valuable resources  defending them when they have simply become a liability.



So paramedicine is not a profession, but a simple technical trade.


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## Veneficus (Dec 6, 2011)

*I think you are missing my whole point*



Corky said:


> Your missing my whole point.  Do you think these EMS outfits have endless funds and lawyers on retainer? I think not.
> 
> Train your people to follow protocols as given by your medical director.  Any variance from protocols why would a company waste valuable resources defending them when they have simply become a liability.



Lawyers sue deep pockets.

They do not waste time on EMTs, they want organizations with insurance and/or lots of cash.

A coperation or organization named in a lawsuit doesn't need to defend the employee. They need to defend themselves. That is why lawyers don't simply name EMS professionals.

It would be a hollow victory. The EMT couldn't meet the resources, but couldn't pay the judgement either. In civil law "I'm sorry I messed up" is said with a payout, not with a judgement.

Follow the money.


----------



## DrankTheKoolaid (Dec 6, 2011)

*re*

No i completely understand they protect you from nothing.  But at least if you followed established protocols you have have some leg to stand on.  And when a expert witness gets up and is asked if they followed standard treatment guidelines they would at least back the provider by saying "Yes this patient was treated per the providers training and established protocols as set by his / or her medical director".  People / entities can be sued for anything at anytime and we can thank bottom feeder lawyers for it..................


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## Veneficus (Dec 6, 2011)

Corky said:


> No i completely understand they protect you from nothing.  But at least if you followed established protocols you have have some leg to stand on.



I seriously urge you not to think this way.

Whether you follow a protocol or not, if you do something that actually causes demonstratable harm, you are responsible.




Corky said:


> And when a expert witness gets up and is asked if they followed standard treatment guidelines they would at least back the provider by saying "Yes this patient was treated per the providers training and established protocols as set by his / or her medical director".



I doubt that very much. Nobody is going to call an expert witness that deosn't back their case.

The plantif will find an expert witness to testify you did something wrong because they have to show cause.

Your defense will call their own expert who will bolster their case.

Eventually it may come down to a third party witness, who will be asked if in their opinion the treatment caused harm, not whether or not you follow protocol.

If 10,000 witnesses testify you follow protocol and even 1 can show that following that protocol lead to damage, it won't matter if that protocol was penned by The divine being of your choice.


----------



## JPINFV (Dec 6, 2011)




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## AMF (Dec 6, 2011)

Veneficus said:


> I love this, it is like saying "my friend is (race x)" before telling a racial joke.
> 
> 
> 
> ...



 I am very new, and I appreciate what you're trying to say.  Though, at least in Maine, it doesn't really matter if you're a paramedic or not.  You follow protocols, because that's what's legally expected of you.  
 Generally, when an EMS provider puts something in quotes, it's because they are the words of someone else.  I arrived after the patient was moved.  
 This patient was critical.  He was not sitting up by himself.  It took several sternal rubs each time for him to open his eyes.  His breathing we fine (<12 though), so I was fine with him not being intubated.
  He was on the bed, and then he wasn't.  His head was on the ground.  He can't move.  He had a laceration/contusion (an elipse, with diameters 3-4 cm by .5-1 cm) that wasn't there before.  Not sure why you think he didn't fall.  

Your questions make me think.  I like that. But as an EMT, thinking is extra.  We are legally bound to do what a little book tells us we have to do.  My question was really about rank.  I didn't think there would any argument about the treatment.


----------



## Aidey (Dec 6, 2011)

Who here has protocols that say a significant fall is 4 feet? Everyone I have worked under usually is something like "20 feet, or more than 3 times body height".


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## JPINFV (Dec 6, 2011)

AMF said:


> Your questions make me think.  I like that. But as an EMT, thinking is extra.  We are legally bound to do what a little book tells us we have to do.  My question was really about rank.  I didn't think there would any argument about the treatment.



One thing to remember is that protocol philosophy varies greatly. Looking through the forward for Maine's protocols make it looks like Maine is very big on "Our EMS providers are simple technicians who are incapable of thinking for themselves, therefore only OLMC can deviate from our cookbook-ocol." 

However, other places will say things like, "We expect paramedics to use their training and good judgment when treating patients in the field and to document situations that vary from the norm," and "Paramedics *have the option* to perform procedures or administer drugs in the non-shaded areas on their own counsel, or to contact the base hospital for consultation." (emphasis NOT added)


----------



## AMF (Dec 6, 2011)

Aidey said:


> Who here has protocols that say a significant fall is 4 feet? Everyone I have worked under usually is something like "20 feet, or more than 3 times body height".



We're taught pt height as a general rule of thumb, but he fell directly on his head.


----------



## Aidey (Dec 6, 2011)

Or he fell directly on his face.


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## AMF (Dec 6, 2011)

JPINFV said:


> One thing to remember is that protocol philosophy varies greatly. Looking through the forward for Maine's protocols make it looks like Maine is very big on "Our EMS providers are simple technicians who are incapable of thinking for themselves, therefore only OLMC can deviate from our cookbook-ocol."
> 
> However, other places will say things like, "We expect paramedics to use their training and good judgment when treating patients in the field and to document situations that vary from the norm," and "Paramedics *have the option* to perform procedures or administer drugs in the non-shaded areas on their own counsel, or to contact the base hospital for consultation." (emphasis NOT added)



Your perception, based on my understanding, is correct.  For example, intermediates can't give drugs with olmc.


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## DrankTheKoolaid (Dec 6, 2011)

*re*

Well the next time you see your Medical Director, who is the physician that allows you to work under HIS or HER license ask them what they want you to do.      Shall we just guess now at what they will say?


----------



## Aidey (Dec 6, 2011)

AMF said:


> I am very new, and I appreciate what you're trying to say.  Though, at least in Maine, it doesn't really matter if you're a paramedic or not.  You follow protocols, because that's what's legally expected of you.
> Generally, when an EMS provider puts something in quotes, it's because they are the words of someone else.  I arrived after the patient was moved.
> *This patient was critical.  He was not sitting up by himself.  It took several sternal rubs each time for him to open his eyes.  His breathing we fine (<12 though), so I was fine with him not being intubated.*
> He was on the bed, and then he wasn't.  His head was on the ground.  He can't move.  He had a laceration/contusion (an elipse, with diameters 3-4 cm by .5-1 cm) that wasn't there before.  Not sure why you think he didn't fall.
> ...



This statement kind of contradicts itself in this circumstance. What exactly was making him critical?


----------



## Tigger (Dec 6, 2011)

Since this happens at a college, were you responding with your college's QRS? If so, from what I understand you are not operating as part of a licensed service (or at least that's what Colby College has to say), so the patient was really never "yours," being that the licensed agency on scene is going to be responsible for the patient.

From Colby EMS's website:


> The State of Maine does not license college based EMS systems because they do not meet certain logistical requirements ( year-round coverage, mutual aid with surrounding communities, etc...). CER operates from protocols set forth by our overseeing medical facility, the Garrison-Foster Health Center. These protocols are similar to current Maine EMS protocols. CER operates on the Colby College Campus under the direction of the Colby Medical Director.


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## STXmedic (Dec 6, 2011)

AMF, why was this pt critical? From what you've posted, you had a kid who was hammered and rolled out of bed, hitting his head on the way out of bed. Short fall (definitely not a significant distance), and he's plastered. You're at a campus I believe? I would assume you've came across plenty of heavily intoxicated patients. Sternal rubs on intoxicated patients are quite normal. Was there severe, active hemorrhage? Were his pupils blown or unequal? Any vomiting at all? Did you try inflicting pain to extremities? From the info you've provided, there isn't really anything to indicate this is a critical patient.


----------



## AMF (Dec 6, 2011)

Tigger said:


> Since this happens at a college, were you responding with your college's QRS? If so, from what I understand you are not operating as part of a licensed service (or at least that's what Colby College has to say), so the patient was really never "yours," being that the licensed agency on scene is going to be responsible for the patient.
> 
> From Colby EMS's website:



We have those things and are licensed as a service.  I've seen the certificate.  I didn't know you could provide medical care outside of a service as an EMT.

We consider a trauma patient that is not wnl in at least 2 areas (from BP, HR, RR, BGL, SpO2, or AMS as determined by the GCS) to by critical.


----------



## STXmedic (Dec 6, 2011)

AMF said:


> We consider a trauma patient that is not wnl in at least 2 areas (from BP, HR, RR, BGL, SpO2, or AMS as determined by the GCS) to by critical.


So a little old lady who's a chronic smoker, BP of 96/50 and a RR of 24ish, maybe pulse ox of 93%, is considered critical? How about a female cross country runner who's got a similar BP and a pulse of 42. Is she critical as well?


----------



## AMF (Dec 6, 2011)

PoeticInjustice said:


> AMF, why was this pt critical? From what you've posted, you had a kid who was hammered and rolled out of bed, hitting his head on the way out of bed. Short fall (definitely not a significant distance), and he's plastered. You're at a campus I believe? I would assume you've came across plenty of heavily intoxicated patients. Sternal rubs on intoxicated patients are quite normal. Was there severe, active hemorrhage? Were his pupils blown or unequal? Any vomiting at all? Did you try inflicting pain to extremities? From the info you've provided, there isn't really anything to indicate this is a critical patient.



No vomiting at all (which I see as a red flag), light hemorrhage, no response to pain in the extremities, and it took several sternal rubs for him to even open his eyes.  He localized, but mvmt was sluggish at best.

Not that it matters if he was critical or not.  Green 12 of the MEMS protocols look like this:
"Head Trama
Basic
1. Immobilize entire spine on long spinal immobilization device.
2. O2 as appropriate
...
Intermediate/Critical Care/Paramedic
7. IV en route
8. If shock present, perform fluid challenge to maintain BP > 90 mmHg
9. Cardiac Monitor
10. Manage airway as needed.  See 'Blue 3 and 5.'
"
There is no paramedic-specific response.  There is no "Immobilize if appropriate."  I just want to know if I can not board an unreliable patient with an unwitnessed fall with visible laceration/contusion and say "the responding paramedic told me not to and since I'm just a cookbook technician who can't think for myself, I thought it'd be okay."


----------



## AMF (Dec 6, 2011)

PoeticInjustice said:


> So a little old lady who's a chronic smoker, BP of 96/50 and a RR of 24ish, maybe pulse ox of 93%, is considered critical? How about a female cross country runner who's got a similar BP and a pulse of 42. Is she critical as well?



No.  They are wnl.  Normal limits are per captia.  I'm not sure why his critical condition matters.  If either of your hypotheticals fell on their head and were unreliable, they'd get boarded as well.


----------



## STXmedic (Dec 6, 2011)

I'm not arguing that your patient shouldn't have been boarded. Personally, I probably would've boarded him as well. Our SMR clearance is also excluded by an unreliable patient (and we had a case here very similar to this that actually did have a spinal injury). It just seems like the condition of this patient is being mildly exaggerated, whether on purpose or out of ignorance.


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## STXmedic (Dec 6, 2011)

AMF said:


> No.  They are wnl.  Normal limits are per captia.  I'm not sure why his critical condition matters.  If either of your hypotheticals fell on their head and were unreliable, they'd get boarded as well.



See, so y'all DO have the ability to use professional judgement, at least to an extent. Don't sell yourself short, guy. EMTs are still required to think instead of just "See this, do that"


----------



## Handsome Robb (Dec 6, 2011)

PoeticInjustice said:


> AMF, why was this pt critical? From what you've posted, you had a kid who was hammered and rolled out of bed, hitting his head on the way out of bed. Short fall (definitely not a significant distance), and he's plastered. You're at a campus I believe? I would assume you've came across plenty of heavily intoxicated patients. Sternal rubs on intoxicated patients are quite normal. Was there severe, active hemorrhage? Were his pupils blown or unequal? Any vomiting at all? Did you try inflicting pain to extremities? From the info you've provided, there isn't really anything to indicate this is a critical patient.



You beat me to the punch. Drunko McGee took a tumble and is heavily intoxicated. I don't see critical anywhere in here.


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## AMF (Dec 6, 2011)

PoeticInjustice said:


> See, so y'all DO have the ability to use professional judgement, at least to an extent. Don't sell yourself short, guy. EMTs are still required to think instead of just "See this, do that"



Not many would agree with you


----------



## Veneficus (Dec 6, 2011)

AMF said:


> I am very new, and I appreciate what you're trying to say.  Though, at least in Maine, it doesn't really matter if you're a paramedic or not.  You follow protocols, because that's what's legally expected of you.
> Generally, when an EMS provider puts something in quotes, it's because they are the words of someone else.  I arrived after the patient was moved.
> This patient was critical.  He was not sitting up by himself.  It took several sternal rubs each time for him to open his eyes.  His breathing we fine (<12 though), so I was fine with him not being intubated.
> He was on the bed, and then he wasn't.  His head was on the ground.  He can't move.  He had a laceration/contusion (an elipse, with diameters 3-4 cm by .5-1 cm) that wasn't there before.  Not sure why you think he didn't fall.



Maybe somebody hit him? Maybe he hit his head puking in the toilet?

If he fell or not is not my issue, the question is does he have a significant enough potential to reasonably cause a catastrophic injury and was there any physical exam finding that supported it?

Ask yourself: 

What do you consider a critical patient?

What do I consider a critical patient?

I'll bet they are not even close to matching.



AMF said:


> But as an EMT, thinking is extra..



Not directed at you , but sometimes I wonder if it is even possible EMTs can think anymore. I remember when they capable providers.




AMF said:


> We are legally bound to do what a little book tells us we have to do.



I know what you were taught.

I know why you were taught that way.

I know you are considered an adult learner and the instruction of your original teacher in your mind is the highest credible source and I am just some moron in typing on the internet telling you something diametrically opposed to brainwashing you got in EMT class.

I also know you are new, and probably haven't seen all that many patients, much less critical ones. 

So in your mind any patient that scares you or otherwise causes stress is critical.

But I would like you to reread my post in response to Corkey, I don't recall the number, but it is the one above JPs football picture. Then think about it.

If you harm a patient, you are wrong. Nevermind the lawsuit, you might harm many and never get sued. But if you cause somebody injury or exaserbate their illness for that little piece of mental security or to satisfy a standing order that cannot possibly account for every circumstance, you are worse than no help at all.

You seem to elevate the position of doctors, of which I know one or two  , Some I like and hold the highest respect for I disagree with on occasion. But I don't know any that would actually have you carry out a treatment without regard as to what that treatment would do to a given patient.

"It's a do no harm" thing.

Now I don't honestly care if your protocol says stick as a pole in the patient's a$$ and spin them around on it, you are called to and trusted to do what is in the best interest of your patient by the highest medical authority. The patient. You have a responsibility to them and that trust to think about what you are advising them and doing to them. 

It is not a bonus.

I think you should go demand your money back from an instructor who did not actually teach you, but instead made you memorize the fears and anxieties they projected upon you.

You may find your career much longer and more rewarding with the calm that knowledge brings. 

Honestly, if you are in medicine to simply do as you are told, you may find better pay in a factory.   



AMF said:


> I didn't think there would any argument about the treatment.



I can argue treatment with just about anyone.

But that is not the point.

Did you know that spinal precautions in a hospital consist of a c-collar and a soft matress?

In fact, I cannot recall one instance of a spineboard being used in any medical environment outside of EMS. Do you think the principles of medicine change when you leave the ivory tower called a hospital?

I am truly sorry your State thinks you are too stupid to make a decision. It is not the only one and a disservice to you as a person. 

But ask yourself, you just told me thinking was optional. So are they really at fault if a majority of the people providing care think that way?

Wouldn't that make you part of the problem?


----------



## abckidsmom (Dec 6, 2011)

AMF said:


> Not many would agree with you



Not many what?  Automatons?

Regardless of your level of care, thinking is completely required in this job.


----------



## Aidey (Dec 6, 2011)

Veneficus said:


> Did you know that spinal precautions in a hospital consist of a c-collar and a soft matress?
> 
> In fact, I cannot recall one instance of a spineboard being used in any medical environment outside of EMS. Do you think the principles of medicine change when you leave the ivory tower called a hospital?



We were called to do a transfer from a smaller ER to a children's ED for a 9yo with possible SCIWORA. The ER requested we bring a backboard. We make contact, and I ask why the backboard. The RN said that she assumed we had to use it, I said nope unless the neurologist said so. His response was "Why the hell would you want to do that?". He did not get transported on a backboard.


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## AMF (Dec 6, 2011)

abckidsmom said:


> Not many what?  Automatons?
> 
> Regardless of your level of care, thinking is completely required in this job.



Some more than others, I think, is the sentiment.



Veneficus said:


> Maybe somebody hit him? Maybe he hit his head puking in the toilet?



Patient was too comatose to vomit.



Veneficus said:


> If he fell or not is not my issue, the question is does he have a significant enough potential to reasonably cause a catastrophic injury and was there any physical exam finding that supported it?
> 
> Ask yourself:
> 
> ...


You think boarding caused the patient harm?  In adding extra extrication time?  The paramedics didn't seem concerned; they were code 1, anyhow.  

I'm not saying that all unreliable patients who fall should get back boarded.  I'm saying that I'm going to backboard them because I don't want to lose my license.  Really pretty straightforward.

I am new, and appreciate your viewpoints.


----------



## Veneficus (Dec 6, 2011)

Aidey said:


> Who here has protocols that say a significant fall is 4 feet? Everyone I have worked under usually is something like "20 feet, or more than 3 times body height".



Aidey,

I find that it is not the hight of the fall that matters it is the type of impact and the relative condition of the patient.

In a blunt force mechanism, (penetrating is a whole different story)

In order to fracture the body of C-1 you need vertical compression.

C-2 hyperextension.

Other vertabrae flexion or extension. With significant flexion, extension, or soft tissue damage leading to subluxation. (and you will definately notice that)

Also the mid cspine(and lumbar) because of the compartment being narrower and the tissue in it being greater, there is more potential for inflammatory process to cause the cord insult than direct trauma.

Granny falling to the floor with a combination of osteoporosis and osteomalacia from standing could be in serious trouble. 

(Psycho feminist note, it is always granny because grandpa dies of an MI at 65 prior to the onset of osteoporosis) 

Additionally if the patient is male and has a prior treatment for prostate CA or a female with breast CA, or really anyone with some sort of myloproliferative disorder or pagets disease of bone, could have minor pathologic fractures that are amplified by less significant forces.


----------



## STXmedic (Dec 6, 2011)

AMF said:


> Patient was too comatose to vomit.



Wait, what?


----------



## Veneficus (Dec 6, 2011)

AMF said:


> Patient was too comatose to vomit.



What???!!! 

Please, I am trying to give you some perspective and knowledge, but you really need to read a bit more before you say things like that. Both the vomiting centers in your brain and stomach do not require consciousness to function. Infact with relaxation of the lower esophageal spincter tone, it can actually increase the chance of vomiting. The same with the neuro center if it loses inhibition.




AMF said:


> You think boarding caused the patient harm?  In adding extra extrication time?  The paramedics didn't seem concerned; they were code 1, anyhow.



Where to begin...

Boarding causes harm by compromising the ability of a patient to self protect the airway. They can vomit and aspirate or get an obstruction with vomiting that doesn't exist the mouth. (let's call it sub clinical) Which can lean to airway obstruction, pneumosepsis, or chronic fibrotic change. (the later reducing the quality of life and earlier copathologies for the rest of their life.)

It restricts chest wall expansion. (which reduces the effectiveness of breathing.)

It can reduce compartments and cause ischemia (especially to the anterior spinal artery and artery of adamkiewicz resulting in paralysis)

It can also cause pressure ulcers and subsequent complications in those too impaired to feel the pain the early damage causes, tohose with circulatory impairment, and the elderly.

Who gives a crap about prolonged transport time?


----------



## Aidey (Dec 6, 2011)

Veneficus said:


> Aidey,
> 
> I find that it is not the hight of the fall that matters it is the type of impact and the relative condition of the patient.
> 
> ...



Or has/had an eating disorder, ESRD, any variety of diseases that cause malabsorption, or is obsessed with Twilight and never goes into the sunlight because they don't want to sparkle.

I know, you know, and anyone who spends any time doing extracurricular reading knows that MOI isn't a great indicator of actual injury. 

It meant it as a literal question. For the non-thinking follow protocol to the letter crowd.


----------



## Veneficus (Dec 6, 2011)

Aidey said:


> Or has/had an eating disorder, ESRD, any variety of diseases that cause malabsorption, or is obsessed with Twilight and never goes into the sunlight because they don't want to sparkle.
> 
> I know, you know, and anyone who spends any time doing extracurricular reading knows that MOI isn't a great indicator of actual injury.
> 
> It meant it as a literal question. For the non-thinking follow protocol to the letter crowd.



My bad, i thought it was a legit question.
I was trying to help.

(I also thought I summed up the absorbtion, liver, renal, and sunlight vit D activation with the osteomalacia nicely   )

It is a good day anytime I can figure out how to use less words.


----------



## AMF (Dec 6, 2011)

Veneficus said:


> What???!!!
> 
> Please, I am trying to give you some perspective and knowledge, but you really need to read a bit more before you say things like that. Both the vomiting centers in your brain and stomach do not require consciousness to function. Infact with relaxation of the lower esophageal spincter tone, it can actually increase the chance of vomiting. The same with the neuro center if it loses inhibition.
> 
> ...


We're not really taught to think like that.  We were never taught CIs to Spinal Immobilization.  It doesn't mean you're wrong, and it doesn't mean there aren't any, but it does mean that when indicated, there is no excuse for not boarding the patient.  
To those who think that a four foot fall on the head (which is about 1000 newtons and has almost a 0% chance of having no horizontal component) is not significant, while I disagree with you, it's kind of irrelevant.  The protocol says that head injury patients get boarded.  Breaking protocol, at the very least, is cause for disciplinary action.   
A practice test question once had me not ked a car accident pt because of concerns over extrication time, which why I asked if that's what you were thinking.


----------



## mycrofft (Dec 6, 2011)

*I disrespect protocols as much as the next person. Honest.*

But frankly there are some Frankies and Stella's out there who absolutely need them. And even then the protocols are not going to make them do better, but give the rest of us leverage to get rid of them when they screw up nonetheless.

Every protocol has the invisible ink part that says "unless something comes up that doesn't jibe with this, then you better know what you're doing or listen to someone who does". The more successful education you get the better able you are to recognize when the case has left the protocol rails.

That said, protocols are as subject to bureaucratic snafu as anything else. Universal backboarding was one. Sufficing a cervical collar for a backboard when the latter is needed is another (especially when it says "at technician's discretion", which means "Want a cigarette, blindfold, or KY?").

Maybe what we need are kinder gentler means of minimizing spinal movement during extrication and transport, then it wouldn't be such a bone of contention. We used the aluminum folding "canvas" Ferno Washington litters with straps as with an ambulance litter and sandbags/Philly collar (no head taping, big sandbags) and never had complaints from receiving hospitals that we jiggered someone's spine. But we did use a short board and long board for extrications and transport when the spine was likely very compromised.

PS: Never too comatose to vomit. Or maybe they weren't comatose, then vomited, and NOW they're comatose. You can certainly be too comatose to manage your own vomit.


----------



## Aidey (Dec 6, 2011)

Veneficus said:


> Boarding causes harm by compromising the ability of a patient to self protect the airway. They can vomit and aspirate or get an obstruction with vomiting that doesn't exist the mouth. (let's call it sub clinical) Which can lean to airway obstruction, pneumosepsis, or chronic fibrotic change. (the later reducing the quality of life and earlier copathologies for the rest of their life.)
> 
> It restricts chest wall expansion. (which reduces the effectiveness of breathing.)
> 
> ...



Just to add to the list.

There is some evidence that c-collars cause a rise in inter-cranial pressure, which is not a good thing, especially if your patient has an actual head injury. 

A small cadaver study showed that even when a c-collar was "properly" fitted it caused hyperextension of the neck. 

Depending on patient shape and size forcing someone to lay flat can cause excessive lordosis of the lumbar spine. This particularly applies to people with big hips/excess lower body fat and people with kyphosis.


----------



## Veneficus (Dec 6, 2011)

AMF said:


> To those who think that a four foot fall on the head (which is about 1000 newtons and has almost a 0% chance of having no horizontal component) is not significant, while I disagree with you, it's kind of irrelevant.



I accept your challange.

Divide that over the surface area, energy lost in force transfer, and the tissue absorbtion.

I will concede there is probably an extremely small chance providing all the factors line up, but at some point it looks like paranoia.

I really feel bad for the people who call 911 where you are from now. If they only knew what they were getting...

(Not because of you personally, but from the absolute barbaric level of medical practice you are held to.)


----------



## Aidey (Dec 6, 2011)

Veneficus said:


> My bad, i thought it was a legit question.
> I was trying to help.
> 
> (I also thought I summed up the absorbtion, liver, renal, and sunlight vit D activation with the osteomalacia nicely   )
> ...



No problem, I should have made it clearer. You did, but I wanted to work that Twilight comment in somehow.


----------



## mycrofft (Dec 6, 2011)

*Don't forget positional asphyxia*

Lay me flat and I cannot breathe due to soft tissue and huge tonsils. Others like the morbidly obese have it even worse.


----------



## AMF (Dec 6, 2011)

Veneficus said:


> I accept your challange.
> 
> Divide that over the surface area, energy lost in force transfer, and the tissue absorbtion.
> 
> ...



I don't.  I'd rather have anything (everything?) you listed than a spinal fracture.


----------



## JPINFV (Dec 6, 2011)

I guess it's too bad that spinal immobilization doesn't prevent spinal fractures.


----------



## Dwindlin (Dec 6, 2011)

JPINFV said:


> I guess it's too bad that spinal immobilization doesn't prevent spinal fractures.



Or improve outcomes of people who have them. . .


----------



## AMF (Dec 7, 2011)

Dwindlin said:


> Or improve outcomes of people who have them. . .



Do you have peer-reviewed evidence of that claim?  I think I know some people who would like to see it.


----------



## JPINFV (Dec 7, 2011)

AMF said:


> Do you have peer-reviewed evidence of that claim?  I think I know some people who would like to see it.



Do you have any peer-reviewed evidence to support the claim that spinal immobilization prevents secondary spinal cord damage?


Spinal immobilization. Recommendation: C, "_Recomendation Summary: There is an insufficient amount of evidence  available to determine if this intervention should be used or not."_
http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=214#Spinal Immobilization


----------



## Handsome Robb (Dec 7, 2011)

AMF said:


> For example, intermediates can't give drugs with olmc.



That's odd. I work as an intermediate and have standing orders for meds...

The fact of the matter here is you don't have to be "taught to think", it should be a spontaneous action. Especially if we want to further this job into a profession.


----------



## mrswicknick (Dec 7, 2011)

To reiterate what everyone else has said, the glaring problem here is that you are treating the pt as a checklist, rather than looking at the over-arching clinical picture. My biggest problem with this if that you are calling this pt critical, when he clearly is not. 

You have trauma secondary to a fall, of low mechanism, with ETOH consumption. You are treating the numbers, not the pt. Yes, your pt has a GCS lower than 15, but can you think of a reason? Look at the situation, the pt is obviously so intoxicated that he urinated all over the floor. Now, assuming you have drank a beer or two before, if you were drunk enough to do that, do you think you would be absolutely alert? No. 

Yes, he has a depressed RR, but is he cyanotic? Cool to the touch? His pupils are sluggish... but why? Again, think about what is causing this. Does a 4 foot drop really sound like something that could cause someone to start circling the drain? Or, could it possibly be the fact that he has again, obviously is incredibly intoxicated and all of these are rxns to depressants like ETOH. Also, why in the hell would you put an OPA in a pt who is vomiting? Vomit in an OPA would cause one hell of a blocked airway, and maybe even cause aspiration. And if you are getting full motor function, I would be you his gag reflex is still in tact, and that he is going to vomit the second you try to get it in, and you will have a true airway problem. Why wouldn't you just suction? 

How about this, what can a medic do for this pt to help him? Per your protocols this is indicated:

Intermediate/Critical Care/Paramedic
7. IV en route
8. If shock present, perform fluid challenge to maintain BP > 90 mmHg
9. Cardiac Monitor
10. Manage airway as needed. See 'Blue 3 and 5.'

Was the pt in shock? If not, then #8 is out of the question. Again, manage the airway, but do you think his airway is compromised due to trauma, or due to the ETOH. Again, look at the clinical picture.

Its a matter of looking at the clinical picture, and having some situational awareness. Where I practice, if I called for ALS in this situation not only would my Medics not transport this pt after an evaluation, but they would chew me out post call for not doing exactly what I just mentioned and taking them away from a pt that truly needs their help. Do you really think its a good Idea to take a medic unit OOS just to transport some joe that drank too much? 

Dont take this as me bashing you. Just as you were, I was in the same situation not too long ago and followed the book to the dot until I was fortunate enough to sit down with our Senior Medics and even our med director to shed some light on what a true critical pt is. I would advise you try and do the same. I hope rather than looking at this as an attack you will see at as another way to think of the practice of care, and begin to further yourself as an EMT.


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## systemet (Dec 7, 2011)

AMF said:


> To those who think that a four foot fall on the head (which is about 1000 newtons and has almost a 0% chance of having no horizontal component) is not significant, while I disagree with you, it's kind of irrelevant.



Any fall on planet earth for a 102 kg object is about 1000N.  I think the kinetic injury and the resulting forces on the vertebrae at impact might be more relevant here.

[Not to mention, did his entire body weight impact at the same time, or was perhaps half his body mass supported by the bed, while his head struck the ground?]



> The protocol says that head injury patients get boarded.  Breaking protocol, at the very least, is cause for disciplinary action.
> A practice test question once had me not ked a car accident pt because of concerns over extrication time, which why I asked if that's what you were thinking.



As I said earlier, I'd probably board this patient too if there's no history.  I wouldn't trust that the laceration on his head didn't happen from being struck with a bat.  I don't trust people in general.

However, if there's clear and reliable evidence that he rolled out of bed, it's hard to see a positive mechanism, even given a very generous interpretation of what constitutes a mechanism.

There's two different arguments at play here:

(1) The argument that it's best for your continuing financial security to remain employed and follow the medical control guidelines in any unclear situation to prevent loss of income / job security.

AND

(2) That it's better you do what's in the best medical interest of the patient.

I don't think anyone is telling you to go out and get fired.  They're simply point out that a lot of the patients we immobilise probably shouldn't be immobilising in the first place, that there's almost no evidence behind this practice, and there is proof of potential harm.  That simple.


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## rescue1 (Dec 7, 2011)

My main concern with boarding the pt, besides the minor MOI and the fact I hate boarding people, is the fact that as a very drunk individual, the pt is almost guaranteed to vomit during transport, and you have to be very quick to roll the board and suction when they do. If the medic rides by himself in the back (which I assume he does), and he's trying to start an IV when this happens, he has to move, roll the board, hold the board on the side, get the suction and suction all by himself very quickly.
I had a paramedic on a call once who wanted to board an intox with no significant MOI (slid down into the grass) because it "would be easy to roll them if they threw up".
It didn't work out so well...it's a good thing we both rode in the back, cause he was a big dude to roll and we had to do it several times. Puked all over me and the medic. I was not a happy man.


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## STXmedic (Dec 7, 2011)

A patient with a very significant MOI with a severe head injury is very likely to vomit, too (let's say motorcycle accident with no helmet). Would you not board this patient? Just saying, there's plenty of reasons to not board somebody. Vomitus should not be your primary reason.


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## AMF (Dec 7, 2011)

systemet said:


> Any fall on planet earth for a 102 kg object is about 1000N.  I think the kinetic injury and the resulting forces on the vertebrae at impact might be more relevant here.
> 
> [Not to mention, did his entire body weight impact at the same time, or was perhaps half his body mass supported by the bed, while his head struck the ground?]
> 
> ...



I'll agree to that.



mrswicknick said:


> To reiterate what everyone else has said, the glaring problem here is that you are treating the pt as a checklist, rather than looking at the over-arching clinical picture. My biggest problem with this if that you are calling this pt critical, when he clearly is not.
> 
> You have trauma secondary to a fall, of low mechanism, with ETOH consumption. You are treating the numbers, not the pt. Yes, your pt has a GCS lower than 15, but can you think of a reason? Look at the situation, the pt is obviously so intoxicated that he urinated all over the floor. Now, assuming you have drank a beer or two before, if you were drunk enough to do that, do you think you would be absolutely alert? No.
> 
> Yes, he has a depressed RR, but is he cyanotic? Cool to the touch? His pupils are sluggish... but why? Again, think about what is causing this. Does a 4 foot drop really sound like something that could cause someone to start circling the drain? Or, could it possibly be the fact that he has again, obviously is incredibly intoxicated and all of these are rxns to depressants like ETOH. Also, why in the hell would you put an OPA in a pt who is vomiting? Vomit in an OPA would cause one hell of a blocked airway, and maybe even cause aspiration. And if you are getting full motor function, I would be you his gag reflex is still in tact, and that he is going to vomit the second you try to get it in, and you will have a true airway problem. Why wouldn't you just suction?


The patient was not vomitting.  The patient did not have full motor function.  The patient did not have a gag reflex.  I'm not sure you read the first post correctly.



mrswicknick said:


> How about this, what can a medic do for this pt to help him? Per your protocols this is indicated:
> 
> Intermediate/Critical Care/Paramedic
> 7. IV en route
> ...



Again, I think you misunderstand.  We're QRS, which means we don't transport.  Are you saying that the patient didn't need transportation?


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## AMF (Dec 7, 2011)

NVRob said:


> That's odd. I work as an intermediate and have standing orders for meds...
> 
> The fact of the matter here is you don't have to be "taught to think", it should be a spontaneous action. Especially if we want to further this job into a profession.


I mean't without OLMC, in the state of Maine.
Intermediates vary quite a bit from state to state.


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## mrswicknick (Dec 7, 2011)

Your missing the point. Are you saying he had no gag reflex because you physically checked, or because you are assuming by the numbers. He is intoxicated, which is why those numbers are the way they are.Looking at the situation and the surroundings you can tell he has had plenty of booze, and seeing as you dont transport I could understand you not recognizing this, but I promise you that pt, especially in the state that he is, may not be presently vomiting, but absolutely will the second the amb he is transported in starts moving. I would not stick a OPA in his mouth, both because I promise you he does have a gag, and because at his level, he absolutely will vomit, and that will cause an obstruction. 

Absolutely he needs to be transported. But he does not need a medic unit. Can you not dispatch a BLS rig for transport?


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## mrswicknick (Dec 7, 2011)

I think overall you are still not getting the point. Treat the pt, not the numbers. Look at the clinical picture. Your pt is not a flow chart.


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## systemet (Dec 7, 2011)

mrswicknick;357957but I promise you that pt said:
			
		

> I think it's fairer to say that there's a much greater risk he'll vomit after being moved around, placed supine and is subject to longitudinal acceleration and deceleration forces.  I wouldn't say it's necessarily guaranteed.
> 
> From an airway management perspective, I can say it's much easier to justify intubating someone because of a failure to oxygenate or ventilate, or wishing to avoid gastric insulfation with PPV, than because of a vague aspiration risk.  Especially if the patient is immobilised, and therefore a greater risk for being a difficult intubation.
> 
> ...


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## rescue1 (Dec 7, 2011)

PoeticInjustice said:


> A patient with a very significant MOI with a severe head injury is very likely to vomit, too (let's say motorcycle accident with no helmet). Would you not board this patient? Just saying, there's plenty of reasons to not board somebody. Vomitus should not be your primary reason.



Of course I would...thats a significant MOI for spinal injury. Being drunk and falling down a couple feet is not. Drunk people fall down all the time without paralyzing themselves. If he'd been sober it's likely he would have either a) used a band aid or b) had someone drive him to the ER. 
You and I both know when that patient got to the ER, he'd be off the board as soon as the doctor said "does your neck/back hurt?" anyway.

Now if the pt had fallen out of a bunk bed, or had unequal pupils, or had some other indication that there was significant trauma, he'd get a board, projectile vomiting or not.


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## mrswicknick (Dec 7, 2011)

Sysetmec, I agree with everything you said, and most of what you are saying I was implying. Its hard sometimes to express what you are thinking in full detail with stuff you assume is already being thought of in the back of your head if that makes any sense. Also, the reason I wouldnt take the time with an ALS rig is I see no immediate life threats, and in my area of practice it would take just as much time to get this pt to the hospital than to wait for an ALS rig to arrive and transport. If I thought airway patency was a true issue on this pt however, I would absolutely snag an ALS rig. Hope that clarifies.


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## AMF (Dec 7, 2011)

mrswicknick said:


> Your missing the point. Are you saying he had no gag reflex because you physically checked, or because you are assuming by the numbers. He is intoxicated, which is why those numbers are the way they are.Looking at the situation and the surroundings you can tell he has had plenty of booze, and seeing as you dont transport I could understand you not recognizing this, but I promise you that pt, especially in the state that he is, may not be presently vomiting, but absolutely will the second the amb he is transported in starts moving. I would not stick a OPA in his mouth, both because I promise you he does have a gag, and because at his level, he absolutely will vomit, and that will cause an obstruction.
> 
> Absolutely he needs to be transported. But he does not need a medic unit. Can you not dispatch a BLS rig for transport?



I don't dispatch anyone.  The company I get dispatched with rides P/P, P/I, and occasionally P/B.  I've never seen a non-paramedic-unit truck, though I know they're common in parts of the country that can't afford paramedics.  



rescue1 said:


> Of course I would...thats a significant MOI for spinal injury. Being drunk and falling down a couple feet is not. Drunk people fall down all the time without paralyzing themselves. If he'd been sober it's likely he would have either a) used a band aid or b) had someone drive him to the ER.
> You and I both know when that patient got to the ER, he'd be off the board as soon as the doctor said "does your neck/back hurt?" anyway.
> 
> Now if the pt had fallen out of a bunk bed, or had unequal pupils, or had some other indication that there was significant trauma, he'd get a board, projectile vomiting or not.



Drunk people fall down all the time without paralyzing themselves, yes.  They also fall down and, on occasion, suffer serious neurological damage.  It is the EMS provider's job to weight the pros and cons of spinal immobilization, like any procedure or intervention, before performing it.  Yet the paramedic did not say to me, "It is my professional opinion that boarding this patient would do more harm than good."  He said, "feel free to board him, but I would suggest against it, not for the patient's well-being, but because I'd rather not carry him down the stairs."  And I can empathize with him.  I didn't want to carry him down the stairs either, gut my primary's intuition was that a) it would not do more harm then good, and that b) it would allow us to cya.  So I guess the question no one wants to answer is, where would you draw the line as to a moi significant enough to want to board?  I know it has to do with a number of clinical signs, as well, but would you, as a basic, or even a paramedic, trust yourself to recognize them?

Also, the patient had no gag reflex.  _Yes, I checked._


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## mrswicknick (Dec 7, 2011)

You dont have to be snippy. You didnt say that you checked for a gag, therefor I assumed. Also, just because we staff BLS only units doesnt mean we cant afford them, we just hold incredibly high standards for our medics, and there is only one program you can go through to become one in our city. (King County Medic One) We, as basics, are trained to recognize the true need for ALS, and dispatch as necessary. It makes sure we have the highest trained medics, and not just any person that went through the community college class and passed their NREMT-P. To any medics that have done that route, I am not saying that you have any less training, but I am sure we all know many people, both BLS and ALS, that shouldn't be practicing emergency medicine.

And yes, I am paid to trust myself to recognize those clinical signs. That is what my training did for me, and why I strive to learn more any chance I get.


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## NomadicMedic (Dec 7, 2011)

mrswicknick said:


> Also, just because we staff BLS only units doesnt mean we cant afford them, we just hold incredibly high standards for our medics, and there is only one program you can go through to become one in our city. (King County Medic One) We, as basics, are trained to recognize the true need for ALS, and dispatch as necessary. It makes sure we have the highest trained medics, and not just any person that went through the community college class and passed their NREMT-P. To any medics that have done that route, I am not saying that you have any less training, but I am sure we all know many people, both BLS and ALS, that shouldn't be practicing emergency medicine.



hahahah. As soon as I saw this, I blew soda out of my nose. You're either a stretcher fetcher with AMR or TriMed and if you're like most of the warm bodies that fill those seats, you're in no position to get snippy over ANYTHING.


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## mrswicknick (Dec 7, 2011)

Like I said, I know a lot of people that shouldn't be doing this job. A lot. Im also a premed student, and have devoted my life to learning about medicine. So no, I am not like my peers.


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## mrswicknick (Dec 7, 2011)

Also, I am not trying to be snippy. In no way am I interested in having a pissing contest over the internet, I am simply trying to put out another perspective. In the whole, it seems like he is treating the numbers, not the pt and the clinical picture, and I felt that adding some perspective, from a EMT-B point of view, might help.


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## NomadicMedic (Dec 7, 2011)

A premed student. Hmm. Good for you. 

The ridiculous "We only call ALS for PTs that need it" quote that is perpetrated by King County Fire and the Private Ambulance companies is a crock. The firefighters are scared to make almost any decision because they're afraid of getting yelled at by a medic who was called out of his recliner. (See: Skyway) And the private ambulance companies are scared to death that someone will say something to a fire fighter or medic and make them look bad. (Try making a PT care  suggestion to a KCMO medic and see how long you're employed.) 

It's simple. This PT may not need a board, but a PT that is so intoxicated that he can't communicate or effectively protect his own airway is most likely going to need a tube. (The OP did say he didn't have a gag, right?) And that is a clear indication for an ALS response. 

And by the way, I take great offense at the statement, “... we have the highest trained medics, and not just any person that went through the community college class and passed their NREMT-P.” I've met some pretty lame KCMO medics that I wouldn't let work on my dog. 

Just sayin'.


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## mrswicknick (Dec 7, 2011)

n7lxi said:


> And by the way, I take great offense at the statement, “... we have the highest trained medics, and not just any person that went through the community college class and passed their NREMT-P.” I've met some pretty lame KCMO medics that I wouldn't let work on my dog.
> 
> Just sayin'.



I have also met many of them that I would trust with my life, and I know many, many others from other areas with different training (see TCC) that I wouldnt let touch me. Maybe I have too much faith in Copass' students, but I find many of them to be some of the best.

I have never once been afraid of getting yelled at by a medic because, at least to this point, I have never called them when I havent needed them, or when I have. Yes, if this pt is having problems keeping his airway patent, I would absolutely have an ALS eval, as I have said before, but from what I am reading I dont think that was the case.


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## JPINFV (Dec 7, 2011)

mrswicknick said:


> Like I said, I know a lot of people that shouldn't be doing this job. A lot. Im also a premed student, and have devoted my life to learning about medicine. So no, I am not like my peers.




Your peers as in young adults, your peers as in college students, or your peers as in pre-meds? 


/[insert comment about how anyone can be pre-med]


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## NomadicMedic (Dec 7, 2011)

You're right. Not the place for this argument. Sorry for the thread hijack.


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## mrswicknick (Dec 7, 2011)

JPINFV said:


> Your peers as in young adults, your peers as in college students, or your peers as in pre-meds?
> 
> 
> /[insert comment about how anyone can be pre-med]



My peers as in the warm bodies ls7 was explaining. I understand anyone can be premed, but it was in reference to the aforementioned warm bodies and how many of them have absolutely no interest in medicine and very little understanding further than the class they took to become a basic.

Why must everything on this forum turn into a personal pissing match? I am only trying to give my perspective, and never did I imply that I was superior to anyone, yet most responses to mine seem to be, rather than educational, a put down.


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## AMF (Dec 7, 2011)

mrswicknick said:


> You dont have to be snippy. You didnt say that you checked for a gag, therefor I assumed. Also, just because we staff BLS only units doesnt mean we cant afford them, we just hold incredibly high standards for our medics, and there is only one program you can go through to become one in our city. (King County Medic One) We, as basics, are trained to recognize the true need for ALS, and dispatch as necessary. It makes sure we have the highest trained medics, and not just any person that went through the community college class and passed their NREMT-P. To any medics that have done that route, I am not saying that you have any less training, but I am sure we all know many people, both BLS and ALS, that shouldn't be practicing emergency medicine.
> 
> And yes, I am paid to trust myself to recognize those clinical signs. That is what my training did for me, and why I strive to learn more any chance I get.



You assumed that I assumed.  I understand that you don't think highly of your fellow EMTs, but try not to assume the worst.

And I'm not being snippy here, I promise:  What are those clinical signs?  Ignore the fall-- what about the patient's presentation would indicate the need for full spinal immobilization?


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## Handsome Robb (Dec 7, 2011)

AMF said:


> So I guess the question no one wants to answer is, where would you draw the line as to a moi significant enough to want to board?  *I know it has to do with a number of clinical signs*, as well, but would you, as a basic, or even a paramedic, trust yourself to recognize them?



Because there is not cut and dry answer. You said it yourself in the part that I bolded above. Spinal motion restriction by mechanism alone has no evidence to support it, you have to look at the whole picture. I posted my protocol for you to see, it leaves the mechanism up to our interpretation as providers. 

Like someone else said, I'm paid to recognize indications for a treatment and trust myself to recognize those indications. I'm a young provider at 22 but I haven't heard any complaints about my decisions in my treatment paths. Constructive criticism is a different story, but I welcome it.


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## medic417 (Dec 7, 2011)

W/o getting drawn into the great amount of bs this topic has generated I will only state once Paramedic arrives they are in charge if they decide they want to be.  Just like when you arrive at the hospital, doctor can ignore you and just take over patient.  

[YOUTUBE]http://www.youtube.com/watch?v=WJ_yQ02xwsM[/YOUTUBE]

[YOUTUBE]http://www.youtube.com/watch?v=Otm4RusESNU&feature=endscreen&NR=1[/YOUTUBE]


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## mrswicknick (Dec 7, 2011)

AMF said:


> You assumed that I assumed.  I understand that you don't think highly of your fellow EMTs, but try not to assume the worst.
> 
> And I'm not being snippy here, I promise:  What are those clinical signs?  Ignore the fall-- what about the patient's presentation would indicate the need for full spinal immobilization?



Position found in, MOI (I would not consider 3-4 feet as significant), any presentation of abnormalities in the spinal exam, obvious deformity, reported pain, and pain response in the lower and upper extremities. 

Now, if someone flew 200 ft on a motorcycle and didnt report any pain in the neck, he's still getting a board. Every situation is different, but its always a matter of using all the tools in your toolbox and making the decision you feel most comfortable with.


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## mrswicknick (Dec 7, 2011)

NVRob said:


> Because there is not cut and dry answer. You said it yourself in the part that I bolded above. Spinal motion restriction by mechanism alone has no evidence to support it, you have to look at the whole picture. I posted my protocol for you to see, it leaves the mechanism up to our interpretation as providers.
> 
> Like someone else said, I'm paid to recognize indications for a treatment and trust myself to recognize those indications. I'm a young provider at 22 but I haven't heard any complaints about my decisions in my treatment paths. Constructive criticism is a different story, but I welcome it.



^^^^ This is exactly what I have been trying to say this whole time. My apologies if it got strewn into much other B/S. I have always been terrible at explaining things over forums, and sorry to anyone that took offense.


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## AMF (Dec 7, 2011)

NVRob said:


> Because there is not cut and dry answer. You said it yourself in the part that I bolded above. Spinal motion restriction by mechanism alone has no evidence to support it, you have to look at the whole picture. I posted my protocol for you to see, it leaves the mechanism up to our interpretation as providers.
> 
> Like someone else said, I'm paid to recognize indications for a treatment and trust myself to recognize those indications. I'm a young provider at 22 but I haven't heard any complaints about my decisions in my treatment paths. Constructive criticism is a different story, but I welcome it.



So, I guess what I'm getting at is would you not board a patient unless they had unequal pupils?  Had unilateral weakness?  Complained of back pain?  Only one of these things is obtainable in unconscious patients.  I'm in EMS because I want to be able to take a good history, so I'm uncomfortable when the patient can't talk.  When I'm uncomfortable, I tend to take precautions.  Sure, that's my training, but it's also my intuition as a human being.  But, by all means, please enlighten me.  Where do you draw the line?


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## Handsome Robb (Dec 7, 2011)

AMF said:


> So, I guess what I'm getting at is would you not board a patient unless they had unequal pupils?  Had unilateral weakness?  Complained of back pain?  Only one of these things is obtainable in unconscious patients.  I'm in EMS because I want to be able to take a good history, so I'm uncomfortable when the patient can't talk.  When I'm uncomfortable, I tend to take precautions.  Sure, that's my training, but it's also my intuition as a human being.  But, by all means, please enlighten me.  Where do you draw the line?



I never said that. Don't try to be cute, please. You're being defensive. You called out a provider with more education and _probably_ experience than yourself and we answered the call.

Just because the patient is unconscious doesn't mean you can't get information about the events prior to your arrival from a bystander. If they fell far enough, crashed their car hard enough, got hit with something hard enough to knock themselves out and remain that way when I arrive or caused other significant injuries they are getting a board unless they are awake, I deem the competent and they refuse and in that case they are signing a refusal of SMR. Ever heard of kinematics of trauma? 

Like I said before, there is no cut and dry line so stop asking me to draw one, please.


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## AMF (Dec 7, 2011)

mrswicknick said:


> Position found in, MOI (I would not consider 3-4 feet as significant), any presentation of abnormalities in the spinal exam, obvious deformity, reported pain, and pain response in the lower and upper extremities.
> 
> Now, if someone flew 200 ft on a motorcycle and didnt report any pain in the neck, he's still getting a board. Every situation is different, but its always a matter of using all the tools in your toolbox and making the decision you feel most comfortable with.


Position found in indicated head trauma.  We'll move past the moi.  Spinal exam is unobtainable due the pt's mental status.  I probably would have done a physical, had I been the primary, but other then the lac/cont, I didn't see any obvious deformity.  Reported pain is obviously something I can't assess.  Pain response is nil in the extremities.  Hence, my unease.


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## AMF (Dec 7, 2011)

NVRob said:


> I never said that. Don't try to be cute, please. You're being defensive. You called out a provider with more education and _probably_ experience than yourself and we answered the call.
> 
> Just because the patient is unconscious doesn't mean you can't get information about the events prior to your arrival from a bystander. If they fell far enough, crashed their car hard enough, got hit with something hard enough to knock themselves out and remain that way when I arrive or caused other significant injuries they are getting a board unless they are awake, I deem the competent and they refuse and in that case they are signing a refusal of SMR. Ever heard of kinematics of trauma?
> 
> Like I said before, there is no cut and dry line so stop asking me to draw one, please.



 I'm not sure what you "never said," but I'm not being defensive.  I'm honestly curious.  Wouldn't you be?  Someone pointed out that there were clinical signs that I could have looked at, which confused me, so I asked.  I'm not sure why you think I didn't get a history from the bystanders, since that's where all this head trauma stuff came from.  But really, I'm looking for clinical signs that definitely indicate or contraindicate boarding that can be observed in the pseudocomatose patient.
Edit: Ahh, I see what you think I thought you said.  No, signs like unequal pupils are just something I would look for to indicated neurological trauma.  I'm not saying that you said that.  But are they wrong?


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## Handsome Robb (Dec 7, 2011)

AMF said:


> I'm not sure what you "never said," but I'm not being defensive.  I'm honestly curious.  Wouldn't you be?  Someone pointed out that there were clinical signs that I could have looked at, which confused me, so I asked.  I'm not sure why you think I didn't get a history from the bystanders, since that's where all this head trauma stuff came from.  But really, I'm looking for clinical signs that definitely indicate or contraindicate boarding that can be observed in the pseudocomatose patient.
> Edit: Ahh, I see what you think I thought you said.  No, signs like unequal pupils are just something I would look for to indicated neurological trauma.  I'm not saying that you said that.  But are they wrong?



No worries and no you aren't wrong. Per your protocols SMR of this patient would have been indicated. Per my protocols it is indicated as well however we have some space for interpretation. Would I board this patient? Probably. Would I be happy about it? Not really. The point I have been trying to make is that mechanism alone is not a good indication of SMR.


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## rescue1 (Dec 7, 2011)

AMF said:


> So, I guess what I'm getting at is would you not board a patient unless they had unequal pupils?  Had unilateral weakness?  Complained of back pain?  Only one of these things is obtainable in unconscious patients.  I'm in EMS because I want to be able to take a good history, so I'm uncomfortable when the patient can't talk.  When I'm uncomfortable, I tend to take precautions.  Sure, that's my training, but it's also my intuition as a human being.  But, by all means, please enlighten me.  Where do you draw the line?



It's a terrible answer for you but...it does kinda depend. Looking at where I'm lying right now (in my bed about 3 feet off the ground), I can safely say that if I fell off my bed I would almost certainly not require spinal immobilization. If I were 95 with a history of previous Fxs and osteoporosis, or if I'm in a bunk 6--7ft off the ground then it's a whole different ball game. It appears the pt did not dangle his head off the side of the bed and fell three feet directly on top of his skull, but more crashed off the bed and happened to take some of the fall on his face/forehead. 
Correct me if I'm wrong about what happened, of course

To put significant MOI in perspective, I jumped off a galloping horse last month (don't ever do that, trust me). It was going around 30mph and I guess I was around 5 feet off the ground. I ended up breaking my leg when I landed (on my side) and I promise you I hit the ground with a hell of a lot more force then your pt did. I had no neck or back pain at all. Hell, I didn't even bruise...minus my fractured fibula.

The sad thing is that spinal immobilization is CYA for 99% of pt's we do it to. I've gotten my board back before I've cleared the hospital many times, since the nurses will remove it after asking "do you have back pain?" and getting a no response from the pt.

That being said, if your paramedic's reason for not boarding him was that he wanted to walk him out instead of carry him, he does not fall into the "making good clinical decisions for the patient" category.

Just use some clinical judgement and don't blindly follow protocol...technically your pt (with GCS 9) is a category B trauma patient per my state's protocol, and you should request a medivac helicopter to transport your patient to the nearest Level 1 trauma center, with no need to consult beforehand with the trauma center and obtain permission. Don't be that guy.


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## AMF (Dec 7, 2011)

rescue1 said:


> It's a terrible answer for you but...it does kinda depend. Looking at where I'm lying right now (in my bed about 3 feet off the ground), I can safely say that if I fell off my bed I would almost certainly not require spinal immobilization. If I were 95 with a history of previous Fxs and osteoporosis, or if I'm in a bunk 6--7ft off the ground then it's a whole different ball game. It appears the pt did not dangle his head off the side of the bed and fell three feet directly on top of his skull, but more crashed off the bed and happened to take some of the fall on his face/forehead.
> Correct me if I'm wrong about what happened, of course
> 
> To put significant MOI in perspective, I jumped off a galloping horse last month (don't ever do that, trust me). It was going around 30mph and I guess I was around 5 feet off the ground. I ended up breaking my leg when I landed (on my side) and I promise you I hit the ground with a hell of a lot more force then your pt did. I had no neck or back pain at all. Hell, I didn't even bruise...minus my fractured fibula.
> ...


Haha I did that when I was a kid.  My back was sore for a good week, though.

Yeah, I recognize that it's just the way I've been taught.  "You>Your partner>Your patient."


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## Aidey (Dec 7, 2011)

rescue1 said:


> That being said, if your paramedic's reason for not boarding him was that he wanted to walk him out instead of carry him, he does not fall into the "making good clinical decisions for the patient" category.



I kind of wonder if it was more "If you want to do this unnecessary intervention fine, but I'm not helping you with it".


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## Fish (Dec 7, 2011)

AMF said:


> Background:
> I work for a QRS, meaning we don't transport.  When we get dispatched, the neighboring ALS service, which usually runs double paramedic, gets dispatched as well.  This service is one of the best in North America; I did my basic ride time with them and have nothing but the utmost respect for them.
> 
> Scenario:
> ...



They do not out rank you if they are not in your service/department, however. It is not "your patient until you transfer care" It is their patient when they arrive on scene seeing as they are a higher Medical Authority. That being said, no Medic in his/her right mind should ever blow off another Medical providers suggestion with a "sure, whatever"


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## rescue1 (Dec 7, 2011)

It's all good...my EMT refresher class still teaches me to give 15lpm of O2 to all patients because it "can't hurt". I can't wait for that to get taken out of the protocol.

All of this being said...if you ever have to make the decision before your transport arrives and you feel better if you board the patient...do it. It's your patient, you're there and we're not, and you're never going to get in trouble for following protocol. Just remember that when it comes to treatment, more is not always better. Every trauma patient doesn't need a backboard, high flow oxygen and a lights and sirens ALS transport.


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## rescue1 (Dec 7, 2011)

Aidey said:


> I kind of wonder if it was more "If you want to do this unnecessary intervention fine, but I'm not helping you with it".



That's still kind of a **** move. If you think something is medically unnecessary, as the highest provider on scene you should be explaining why you don't want it performed. It's not like you're free of liability if that treatment goes wrong...you were the paramedic, pt care was your responsibility.


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## Fish (Dec 7, 2011)

rescue1 said:


> That's still kind of a **** move. If you think something is medically unnecessary, as the highest provider on scene you should be explaining why you don't want it performed. It's not like you're free of liability if that treatment goes wrong...you were the paramedic, pt care was your responsibility.



I'll agree with that, It is my Patient as the Medic. If the BLS FF on scene says oi, I wanna backboard a particular patient that I do not feels needs it I am not going to say sure, if you want to. It is a yes, or a No. And if it is a no it is a respectful no, more of a "Eh, I don't really think we he/she needs that" and if they take issue with it they can express why, incase there was something I was missing here. And if I still feel like it is a no, then it is a no and I will tell them I will call them after the call to explain why.


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## Aidey (Dec 7, 2011)

rescue1 said:


> That's still kind of a **** move. If you think something is medically unnecessary, as the highest provider on scene you should be explaining why you don't want it performed. It's not like you're free of liability if that treatment goes wrong...you were the paramedic, pt care was your responsibility.



Sure it is a **** move, but sometimes it can be easier to look like a lazy **** than be an argumentative ****.


----------



## rescue1 (Dec 7, 2011)

Eh, true. Still doesn't make it right, though.


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## Handsome Robb (Dec 7, 2011)

Aidey said:


> Sure it is a **** move, but sometimes it can be easier to look like a lazy **** than be an argumentative ****.



Does letting the FD carry many of our patients down stairs and what not make me fall into that category? By all means I have no problem doing it myself but if they're all over it I'm not going to ruin their fun. 

Edited for stupid iPhone autocorrect.


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## Tigger (Dec 8, 2011)

AMF said:


> But as an EMT, thinking is extra.  We are legally bound to do what a little book tells us we have to do.  My question was really about rank.  I didn't think there would any argument about the treatment.





AMF said:


> It is the EMS provider's job to weight the pros and cons of spinal immobilization, like any procedure or intervention, before performing it.[/I]



Do you see these statements as a bit contradictory? 

Exhaustive protocols and restrictive standing orders have eliminated a great deal of decision making for field providers in some places, but you still need the knowledge to decide when to implement an intervention or follow a protocol. That sort of thinking is the most important part. Just because a treatment or intervention is not contraindicated does not make it indicated. While it is reasonably likely that boarding this patient will ddoue little further harm, doing something only to follow protocol or cover your bum is a poor clinical decision. If you cannot medically justify something, don't do it. 

I think that many in EMS are unnecessarily afraid of losing their license to practice. It is more likely that one loses their license for doing something that they should not have than failing to do something. When it comes to SMR this becomes even more true given that their is some evidence that it doesn't improve any outcomes.


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## systemet (Dec 8, 2011)

AMF said:


> Position found in indicated head trauma.  We'll move past the moi.



While I've been told by medical directors past that if I bring in an intoxicated patient with altered LOC and photogenic head trauma, and there's a c-spine issue, they'll hang me out to dry -- I'm not sure that the location the patient is found in gives us the MOI here.

Did anyone reliable witness the traumatic event?  Did he just roll out of bed (if so / no c-spine needed), or did he get beat up by four guys in a parking lot after doing a bunch of coke, crawl home and pass out on the floor?  Are we able to distinguish these two events based on the information present?

Because if he's just rolled out of bed, the c-spine isn't indicated.  But if you're planning on doing a 1,000 calls / year for the next 20-30 years, you want to be pretty sure when you're making decisions that you're going to be held accountable for.



> Spinal exam is unobtainable due the pt's mental status.



Well, strictly speaking, the physical examination is still present, it's just limited by the ability of the patient to describe their neurological function.  Likewise the history is compromised by the patients LOC, but might be provided by bystanders.

It seems like this is going around in circles.  Here's some quick opinions:

* Clinical practice guidelines may vary by location, by country, county / state / province, and even by city, or ambulance service.

* The overwhelming majority of patients receiving c-spine precautions in North America do not have unstable c-spine fractures, nor are they at risk for unstable c-spine fractures. 

* C-spine precautions are routinely overapplied in situations where they're not clinical indicated with detriment to the patients involved. 

* While NEXUS and Canadian C-spine Rule attempt to provide evidence-based criteria for rule out in conscious, sober, alert, adults with minor mechanisms, there are no evidence based guidlines for situations like the one you describe.

* This is a grey area.  Protocols are written on the assumption that the world is black-and-white.  It's not.  This is why the provider should be sufficiently educated and experienced to apply them as guidelines.

* A lot of systems and a lot of medical directors would rather just avoid the ethical and legal consequences of someone poorly trained, or having a bad day, applying judgment inappropriately, so they accept a small degree of harm to a large number of patients to avoid a large degree of harm to a small number of patients.  This in itself should define why this situation is a grey area.


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## Veneficus (Dec 8, 2011)

*May I?*



AMF said:


> So, I guess what I'm getting at is would you not board a patient unless they had unequal pupils?  Had unilateral weakness?  Complained of back pain?  Only one of these things is obtainable in unconscious patients.  I'm in EMS because I want to be able to take a good history, so I'm uncomfortable when the patient can't talk.  When I'm uncomfortable, I tend to take precautions.  Sure, that's my training, but it's also my intuition as a human being.  But, by all means, please enlighten me.  Where do you draw the line?



I would like to point out to you there is a difference between head injury and spinal injury. 

While brain injury and spinal injury can exist concurrently, it is not automatic.

It may benefit you to review the signs and symptoms of two.

There is a myriad of neuological exams and findings in an unconscious patient. Like Babinski or deep tendon reflexes.

If you patient was actively resisting you, which I understand that to be the case at least at some point from your original description, even more neuro findings are possible if you know what you are looking for and how.

If you became a Basic EMT to be good at history and physical, you wasted your time. Unless you went to some extreme basic class, I am willing to bet you probably know much less than you think about it.

A history and physical starts with paleopathology and epidemiology. If you nothing about either, you are already at a disadvantage.

Books detailing a complete history and physical exam are almost as many pages as your EMT text and written at a far higher level than 8th grade. If you tried to highlight the important parts, you might as well use a paintbrush the important details are so densely presented.

The truth comes out.

You are uncomfortable with patients. That is not a sin. Everyone starts that way. But patient condition is not dictated by provider comfort.

I suspect you may never have seen a patient that requires the full efforts of multiple highly capable providers to manage. That is not a sin either, as many in EMS do not see these patients regularly or regularly enough to be comfortable.

But it is important to understand where you stand.

The first act of taking care of patients you are uncomfortable with is calling somebody with more knowledge and/or experience. 

That was done. So the next step is to learn.

There is a cost to medicine in the US. It is not free and it is rarely forgiven. If you start performing unindicated procedures or tests because of your lack of comfort you can cause the patient unneeded harm.

Performing every test and treatment "just in case" is the mark of a hobbyist who is guessing and really has no idea.

Aka, worse than no help at all.

Going with your gut instead of your head. 

Because let's call a spade a spade, you have intuition but barely demonstrated any knowledge so far.

Do you think it would negatively affect a patient if your "gut" told you the patient's chest pain was caused by an MI and you treated it when in fact it was a ruptured aneurysm because you didn't have enough knowledge in your head to tell between the two?

Would the emotion to do "something" overcome the rationale that you may be in over your head and err on the side of doing nothing in order to not make matters worse?

(don't answer here, just think about it.)


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## Veneficus (Dec 8, 2011)

rescue1 said:


> Just use some clinical judgement and don't blindly follow protocol...technically your pt (with GCS 9) is a category B trauma patient per my state's protocol, and you should request a medivac helicopter to transport your patient to the nearest Level 1 trauma center, with no need to consult beforehand with the trauma center and obtain permission. Don't be that guy.



You must e from MD, where the revenue generated by outrageous airmedical use supercedes patient benefit by any justifyable measure. 

If anyone reading this ever called a helicopyter for this, I hope the patient sends the multithousand dollar bill  right to your agency or you directly if you are a volunteer. With a note from their lawyer thanking you.

The very reason you don't need to call med control is so there is no responsibility conveyed to a Dr. for such a decision.


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## AMF (Dec 8, 2011)

Veneficus said:


> There is a myriad of neuological exams and findings in an unconscious patient. Like Babinski or deep tendon reflexes.
> 
> If you patient was actively resisting you, which I understand that to be the case at least at some point from your original description, even more neuro findings are possible if you know what you are looking for and how.
> 
> ...



That myriad of neurological exams is what I was talking about.  Not in my scope, so I can't write it in a run report or anything, but good to know nonetheless.  

Who do you think I'm at a disadvantage compared to?  Myself if I wasn't EMT-B?  I think that's doubtful.  I think I've made it pretty clear that I don't think I'm an expert.  As for head injury vs spinal injury, while I can appreciate the the difference to some degree, so can the board of medical directors who put head injury as an indication for spinal immobilization.  

Overtreating is a big issue, particularly in our specialty, but I don't really think that's the concern here.  The point that several have brought up that really bothers me is that boarding a patient could do more harm than good.  Other than that, I absolutely agree with everything you're saying.


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## JPINFV (Dec 8, 2011)

AMF said:


> That myriad of neurological exams is what I was talking about.  Not in my scope, so I can't write it in a run report or anything, but good to know nonetheless.



A physical exam is outside of your scope of practice? Does your scope of practice limit what signs you can look for during a physical exam? What's the point of continuing education if you can't implement it?


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## rescue1 (Dec 8, 2011)

Veneficus said:


> You must e from MD, where the revenue generated by outrageous airmedical use supercedes patient benefit by any justifyable measure.
> 
> If anyone reading this ever called a helicopyter for this, I hope the patient sends the multithousand dollar bill  right to your agency or you directly if you are a volunteer. With a note from their lawyer thanking you.
> 
> The very reason you don't need to call med control is so there is no responsibility conveyed to a Dr. for such a decision.



How did you guess? <_<

I once had a paramedic state emphatically that an emotional disorder patient involved in an extremely minor accident (25 mph into a curb) was category B trauma due to her altered mental status...luckily saner heads prevailed and the helicopter was canceled.

Though to be fair, I believe if the State Police fly you in Maryland, you fly for free.


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## medic417 (Dec 8, 2011)

rescue1 said:


> How did you guess? <_<
> 
> I once had a paramedic state emphatically that an emotional disorder patient involved in an extremely minor accident (25 mph into a curb) was category B trauma due to her altered mental status...luckily saner heads prevailed and the helicopter was canceled.
> 
> Though to be fair, I believe if the State Police fly you in Maryland, you fly for free.



Maybe free to patient but costs tax payers a ton.


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## rescue1 (Dec 8, 2011)

Yeah true. I don't mind a tax based system...but in Maryland you can fly people who stub their toe if you feel the urge (and some people will try). 
That being said, my local (small town) hospital won't accept most trauma, and I'm at least an hour from any trauma center. If I take someone by ground, ALS will be with us, meaning I'm taking away half of the county's ALS coverage (only 2 ALS cars in the county) for at least two hours, if not three. It's unfortunate that the situation exists, but sometimes for us, the helicopter is the best option simply because it prevents areas of the county from being left without coverage.


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## Veneficus (Dec 8, 2011)

rescue1 said:


> Though to be fair, I believe if the State Police fly you in Maryland, you fly for free.



But you still get a bill where you land. 

There is a shortage of both trauma and critical care surgeons, so those bills are never going to be cheap.


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## Veneficus (Dec 8, 2011)

JPINFV said:


> A physical exam is outside of your scope of practice? Does your scope of practice limit what signs you can look for during a physical exam? What's the point of continuing education if you can't implement it?



To be fair to AMF, yes, his/her physical exam is limited.

But probably not as drastic as was stated. 

An EMT-B better not be doing any sort of Gyn exam in the field other than checking for crowning or bleeding.

Digital rectal and rectoscopy is also right out. (as they say on monty python)

However, short of that, I cannot think of one State or any place I have ever heard of that limits neuro exams, non invasive physical exam, heart sounds, opthalmoscopy, otoscopy, rectal temperature, or any other form inspection, auscultation, palpation, or percussion not specifically excluded above.

The only caution I would offer is if you don't know how to do it, you probably shouldn't document what you think you find, or keep it real vague, like " potentially adnomal heart tones that may require further investigation."


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## AMF (Dec 8, 2011)

Veneficus said:


> To be fair to AMF, yes, his/her physical exam is limited.
> 
> But probably not as drastic as was stated.
> 
> ...



By don't know, do you mean not properly/officially trained?  I've never heard of an EMT CME class covering physicals (although I haven't taken PHTLS yet, and I suspect they might do something like that)


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## JPINFV (Dec 8, 2011)

Any CME class that covers any disease process is also going to cover signs and symptoms of the disease. Besides, there's always the concept of life long learning. You don't need an instructor to pick up a book like Bates and integrate what you learn into your practice of prehospital medicine.

Edit: I also know of a case where a paramedic caught a dystonic reaction from what he learned from a scenario on an EMS forum. He did contact medical control to confirm the diagnosis and treatment, but without incorporating what he learned he would have never called medical control in the first place.

http://www.emtcity.com/index.php/topic/14938-emtcity-helped-me-make-the-diagnosis/


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## Veneficus (Dec 8, 2011)

AMF said:


> Who do you think I'm at a disadvantage compared to?



I think you are at a disadvantage to somebody who actually knows what they are doing.

I think that that is a major disservice to a patient. 

I am not saying you are responsible for the failure of US EMS training.

But I think this case points out a very harsh reality. 

EMS training is based around injuries and illnesses that are very high severity.

However, these patients are a minority of the ones that are seen and the curriculum, while it has had basic science emphasized, it is still woefully inadequete when it comes to determining sick/not sick. 

When over treatment costs increase, it devaluates the people providing it. Anyone can over treat, but it takes skill to be accurate, which is economically efficent. 

But what it means to the provider in the field is:

You're not getting a raise.

...and who couldn't use a raise?

What it means to all of the "pre-med" or those aspiring to other healthcare professions is that your time and efforts in EMS will not be appreciated in your respective future.

When you work hard and sacrifice and it doesn't pay out later, that just sucks. It is a wate of time and money.


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## AMF (Dec 8, 2011)

Veneficus said:


> What it means to all of the "pre-med" or those aspiring to other healthcare professions is that your time and efforts in EMS will not be appreciated in your respective future.
> 
> When you work hard and sacrifice and it doesn't pay out later, that just sucks. It is a wate of time and money.



Well, that's just, like, your opinion, man.

In all seriousness, I've certainly come to appreciate being an EMT.  If you mean adcoms won't appreciate it, I'll admit that many pre-health students have certifications in EMS or pharm, but it definitely hurts not to have it.  Or so I'm told.


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## JPINFV (Dec 8, 2011)

AMF said:


> In all seriousness, I've certainly come to appreciate being an EMT.  If you mean adcoms won't appreciate it, I'll admit that many pre-health students have certifications in EMS or pharm, *but it definitely hurts not to have it.*  Or so I'm told.



It definitely doesn't hurt to not have an EMS certification, especially since there are plenty of experiences equal to or superior to EMS experience. What can hurt, though, is overvaluing EMT training and certification, especially for the pre-meds who have the certification but never use it.


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## Veneficus (Dec 8, 2011)

AMF said:


> Well, that's just, like, your opinion, man.
> 
> In all seriousness, I've certainly come to appreciate being an EMT.  If you mean adcoms won't appreciate it, I'll admit that many pre-health students have certifications in EMS or pharm, but it definitely hurts not to have it.  Or so I'm told.



:rofl:

The poor creatures, they don't know any better...


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## rhan101277 (Dec 8, 2011)

Veneficus said:


> Performing every test and treatment "just in case" is the mark of a hobbyist who is guessing and really has no idea.



While this statement has some merit, sometimes people themselves aren't sure what is wrong with them and a little more digging needs to be done.  They give a poor chief complaint like, "I feel sick", "I just don't feel right", "I am in a fog" etc.

It is also a "fools errand" to get tunnel vision and not think of all the differentials that could be the cause.


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## Veneficus (Dec 8, 2011)

rhan101277 said:


> While this statement has some merit, sometimes people themselves aren't sure what is wrong with them and a little more digging needs to be done.  They give a poor chief complaint like, "I feel sick", "I just don't feel right", "I am in a fog" etc.



That is a normal day at the office, especially in geriatrics who seem to only have a handful of symptoms that manifest similarly in every possible disease. 





rhan101277 said:


> It is also a "fools errand" to get tunnel vision and not think of all the differentials that could be the cause.



There is a big difference between casting a wide net to make sure you leave nothing out and throwing everything at somebody hoping something sticks.


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## firetender (Dec 8, 2011)

Veneficus said:


> There is a big difference between casting a wide net to make sure you leave nothing out and throwing everything at somebody hoping something sticks.


 
Don't forget, Vene, you are speaking from a place of having been exposed to the ins and outs and ramifications and sub- and advanced levels of diagnosis backed by a thorough study of disease entities. 

Here, you're dealing with people who aspire to gain just a small piece of your knowledge while essentially working in a (non-self imposed) tunnel. 

"throwing everything at somebody hoping something sticks" often becomes part of EVERYONE'S learning curve that helps them understand using the proper limits of a net.


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## JPINFV (Dec 8, 2011)

Something else to think about. The maximum shotgun approach possible in the average EMS system is often going to amount to a basic initial assessment for a physician. It's not like the average paramedic is going to be able to shotgun lab tests outside of a BGL or order a CT, or any similar imaging test.


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## Veneficus (Dec 9, 2011)

*very fine points, but let me try to respond in 1 post*



firetender said:


> Don't forget, Vene, you are speaking from a place of having been exposed to the ins and outs and ramifications and sub- and advanced levels of diagnosis backed by a thorough study of disease entities.
> 
> Here, you're dealing with people who aspire to gain just a small piece of your knowledge while essentially working in a (non-self imposed) tunnel.
> 
> "throwing everything at somebody hoping something sticks" often becomes part of EVERYONE'S learning curve that helps them understand using the proper limits of a net.



Firetender, 

You once again bring out a very good point and perspective.

In this post, I have read more than 11 pages of: "I can't."

Then there are a bunch of excuses as to why.

Most of which are total BS.

It begs the question:

Is there anything you actually can do?

I have read your work, twice. Though it was not pointed out specifically your whole book is about doing what you can with what you have.

Not making excuses for only doing what you did.

I admit that even today the tunnel you speak of in EMS is getting smaller and smaller. However, in this thread I see a self imposed tunnel that doesn't really exist. It probably boarders on agoraphobia.

Providers do not magically get smarter the day they get a specific degree in hand, they get smarter over the journey of obtaining that minimal measurable level.

The quest for more knowledge and more ability needs to be constant from the start. It is a personal quality, not reflected by cert level. I am certain we both know Basic EMTs we would put our faith and trust in. At the same time I have no doubt there are doctors we wouldn't.

If you cannot breach the glass ceiling, expand laterally. 



> Something else to think about. The maximum shotgun approach possible in the average EMS system is often going to amount to a basic initial assessment for a physician. It's not like the average paramedic is going to be able to shotgun lab tests outside of a BGL or order a CT, or any similar imaging test.



It is not just about lab tests or diagnostics. (which are over used anyway but that is a thread for a different forum)

The average system paramedic can do considerable harm with their "what ifs" particularly on the economic health of patients, which you know has actual health consequences in the long term in psychological and physiological stressors.

As was mentioned in this thread, one uncomfortable EMS provider has the ability to inflict thousands of dollars (if not tens of thousands) of harm because of their anxiety and inepness. Not only do they receive no sanction for this, the system is set up to perpetuate it. 

The EMS provider does not see or have to deal with the fallout. They simply ignore it, or justify it as "Better safe than sorry." But when a family breaks up because of medical bills, becomes homeless, or winds up eating McDs 3 meals a day because it is the cheapest meal they can buy, they will not be safe and they will be sorry. 

Take the helicopter out of the equation, research the difference in cost at your local hospital hospital for a trauma activation vs. an ED visit.

Tis not the season to tell kids there are no gifts because they had to pay to "be safe and get checked out because what if..." because the healthcare provider they put their trust in didn't make reasonable recommendations.


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## systemet (Dec 9, 2011)

JPINFV said:


> Any CME class that covers any disease process is also going to cover signs and symptoms of the disease. Besides, there's always the concept of life long learning. You don't need an instructor to pick up a book like Bates and integrate what you learn into your practice of prehospital medicine.



This is an excellent point.  Something I realised after a few years of university was that a large percentage of the knowledge I'd learned was going to decay over time, or never be directly useful to me.  However, what the experience did teach me, was how to teach myself.  This is invaluable.



> Edit: I also know of a case where a paramedic caught a dystonic reaction from what he learned from a scenario on an EMS forum. He did contact medical control to confirm the diagnosis and treatment, but without incorporating what he learned he would have never called medical control in the first place.
> 
> http://www.emtcity.com/index.php/topic/14938-emtcity-helped-me-make-the-diagnosis/



I think this is basic material that should be covered in a paramedic class (fortunately, it was in mine), especially if providers are going to be running around giving stemitil, haloperidol, droperidol, metoclopramide, etc.  

I've seen a couple.  One was an intentional haldol OD who had been discharged and developed dystonia at +48 hours.  (My student worked this out by himself, and recognised the need for benadryl -- I was very proud).  Another was in a family MD's office.  He had called a neurologist at the receiving facility and told the patient he was having a CVA (I think he tunneled in on the oculogyrus), and wanted us to give 100mg meperidine IVP.  

I think that there is nothing that I know as a paramedic that an EMT can't know, or be trained to understand.  Even if they can't treat a dystonic reaction, does this mean that they shouldn't be able to recognise it?  We're putting them on ambulances and sending them to people who call for help.  An extra year or two of education might not hurt this.  I realise that I'm preaching to the choir here.


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## Veneficus (Dec 9, 2011)

systemet said:


> This is an excellent point.  Something I realised after a few years of university was that a large percentage of the knowledge I'd learned was going to decay over time, or never be directly useful to me.  However, what the experience did teach me, was how to teach myself.  This is invaluable.
> 
> 
> 
> ...



I think that is becomming obvious to more people that the minimum knowledge needed to function in today's medicine is considerably larger than what was needed when the idea of a provider who could do some basic interventions on the way to the hospital was formulated.

It is nice to see people actually catching onto the concept, even if they are still the minority.


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## medichopeful (Dec 9, 2011)

AMF said:


> But as an EMT, thinking is extra.



That's one of the scariest statements on this site I've ever seen h34r:


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## Tigger (Dec 10, 2011)

medichopeful said:


> That's one of the scariest statements on this site I've ever seen h34r:



Yes, yes it is.


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## usafmedic45 (Dec 10, 2011)

> You must e from MD, where the revenue generated by outrageous airmedical use supercedes patient benefit by any justifyable measure.



Nah, they don't bill for the MSP flights.  They just take it out in a tax on automobile registration.  Not that it makes it any more medically justifiable....



> luckily saner heads prevailed and the helicopter was canceled.



That's a first.  They killed several people (including a friend of mine) because some girl had a dent in her car that was going to be expensive to have fixed. 



> That being said, my local (small town) hospital won't accept most trauma, and I'm at least an hour from any trauma center. If I take someone by ground, ALS will be with us, meaning I'm taking away half of the county's ALS coverage (only 2 ALS cars in the county) for at least two hours, if not three. It's unfortunate that the situation exists, but sometimes for us, the helicopter is the best option simply because it prevents areas of the county from being left without coverage.



LOL That's the most flawed logic I've seen in a while on EMTLife regarding HEMS. 



> How did you guess?



The smell of Kool-Aid and an inability to think non-linearly? 



> Just use some clinical judgement and don't blindly follow protocol...technically your pt (with GCS 9) is a category B trauma patient per my state's protocol, and you should request a medivac helicopter to transport your patient to the nearest Level 1 trauma center, with no need to consult beforehand with the trauma center and obtain permission. Don't be that guy.



Hmmm....always wondered what it would have been like to be an EMS provider in the mid-1980s.  Then I was stationed in Maryland in 2001 and don't have to wonder any longer.  

What's funny but the "it puts the patient in the helicopter or else it gets the hose again" caveat in the Maryland EMS protocols is the exact same one that existed in our protocols.  The difference was the option of aeromedical evacuation was listed at the very bottom, surrounded by a bold red box containing the following statement in large font letters:
"Medical helicopters delay access to vital medical care and have no appreciable effect upon survival rates.  Utilization of an aeromedical helicopter will result in suspension from clinical duties until such time as an investigation into the circumstances resulting in the request for a scene response has been completed.  Punishment for excessive, egregious or medically unsupportable use of a helicopter may include further suspension, termination of employment or initiation of proceedings to revoke state certifications held by the offending individuals."


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## rescue1 (Dec 10, 2011)

usafmedic45 said:


> LOL That's the most flawed logic I've seen in a while on EMTLife regarding HEMS.



Haha, hey, I try. But I think if you understood the messed up crap that is Kent County EMS you might be (slightly) more forgiving. I'm not saying what's happening is good...but for now, that's just what it is.
Until I get the hell out of here in May, anyway.


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## systemet (Dec 10, 2011)

rescue1 said:


> That being said, my local (small town) hospital won't accept most trauma, and I'm at least an hour from any trauma center. If I take someone by ground, ALS will be with us, meaning I'm taking away half of the county's ALS coverage (only 2 ALS cars in the county) for at least two hours, if not three. It's unfortunate that the situation exists, but sometimes for us, the helicopter is the best option simply because it prevents areas of the county from being left without coverage.



I missed this gem the first time, and then saw that usaf had responded to it.  I've just got to add my .02 to this.  

Please, please, be smarter than this.

You want to take a rotary wing air ambulance out of service with a subacute patient, who could be managed adequately by ground ALS, because you don't want to compromise the coverage for your county, in case there's no ALS when a hypothetical future call comes in?

Do you have any idea how much of a disservice that is to the flight crew, who put themselves at personal risk every day?  Or every other person who lives and breathes anywhere within about 0.5-1.5 hours drive of the HEMS station?  Now you have a real time-critical peds trauma 90 minutes by ground from the trauma center, but the helicopter is busy flying a patient who doesn't need their level of care, so that the coverage in your neighbourhood is safe?  Not even remotely acceptable!

Your county's lack of tax base, political leadership, decent hospital, etc. doesn't get to trump everybody else's needs.


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## usafmedic45 (Dec 10, 2011)

> lack of tax base



It's Kent County.  There's nothing lacking about the tax base.  It's just that the state EMS "authorities" have gotten hospitals so convinced that everyone who is even sporting abrasions needs to be seen at a trauma center, that few hospitals are willing to accept a "trauma patient" without said designation.  It would be quite a comical situation if it weren't so damn risky because Shock Trauma- the crown jewel/polished turd of Maryland EMS- isn't even an accredited trauma center by the same body as everyone else.  It's one of those "We're a trauma center because we say we are!" sort of defenses.  This of course unless something has drastically changed since the Trooper 2 crash in terms of oversight but I seriously doubt it.


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## usafmedic45 (Dec 10, 2011)

> But I think if you understood the messed up crap that is Kent County EMS you might be (slightly) more forgiving.



There isn't a county in that state that has their :censored::censored::censored::censored: together as far as EMS goes.  It would take a full out coup (with the requisite "removal" of people who stand in the way) to get that state moved forward into the 1990s. 


NOTE: I am in no way advocating harming the MIEMSS "leadership", just simply pointing out that until such time as the current "leadership" goes away things will never get any better.


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## JPINFV (Dec 10, 2011)

usafmedic45 said:


> NOTE: I am in no way advocating harming the MIEMSS "leadership", just simply pointing out that until such time as the current "leadership" goes away things will never get any better.




...but I'd love to see a bunch of EMS professionals go all Arab Spring on a bunch of EMS administrators nostalgic for _Emergency!_


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## rescue1 (Dec 11, 2011)

usafmedic45 said:


> It's Kent County.  There's nothing lacking about the tax base.  It's just that the state EMS "authorities" have gotten hospitals so convinced that everyone who is even sporting abrasions needs to be seen at a trauma center, that few hospitals are willing to accept a "trauma patient" without said designation.  It would be quite a comical situation if it weren't so damn risky because Shock Trauma- the crown jewel/polished turd of Maryland EMS- isn't even an accredited trauma center by the same body as everyone else.  It's one of those "We're a trauma center because we say we are!" sort of defenses.  This of course unless something has drastically changed since the Trooper 2 crash in terms of oversight but I seriously doubt it.



There was some minor changes after Trooper 2, I believe, but it happened right before I got into EMS, so I'm honestly not sure. There was a push to cut back on flying patients, and maybe the numbers did go down, but I can tell you, lots of people still fly.

As for systemmet's response, two points. 
I would love to take people to Chester River Hospital all the time. It's close and I know I've been on flyouts where the patient has almost certainly walked out of Shock Trauma that night. 
But, as a lowly BLS provider, it's one, not even my call. We get ALS on all calls, so it's the paramedic's decision as to when to fly. If I suggested taking the patient to Christina Hospital (closest trauma center) by ground, I'd bet you large sums of money that I'd be spending the call outside the ambulance. It's very ingrained in the culture here...and it makes sense why, from a selfish viewpoint. It's really easy to just wait around a few extra minutes for a helicopter and be done with it, as opposed to driving an hour yourself. This is helped by the fact that QA will probably jump on your *** for not following protocol with helicopter activation if you do take a trauma pt more then 30 minutes away by ground.

Is it good? No. It's stupid. But until something changes, like usafmedic45 said, it's something I have to live with. At least until I graduate college and get back to PA.

As for your comment about removing helicopter coverage for an area by tying it up with non-critical patients, almost everywhere in Maryland can get a helicopter in 20-25 minutes, even if the closest one is busy. Medivac coverage will never, ever be an issue in this state.


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## systemet (Dec 12, 2011)

rescue1 said:


> As for systemmet's response, two points.
> I would love to take people to Chester River Hospital all the time. It's close and I know I've been on flyouts where the patient has almost certainly walked out of Shock Trauma that night.
> But, as a lowly BLS provider, it's one, not even my call.



Sorry, I somehow got the impression that launching the chopper was your call.  I apologise for giving you :censored::censored::censored::censored: for someone else's decision / responsibility.  But please recognise that this practice of justifying overutilisation of the helicopter to preserve local coverage is terrible from a medical and ethical standpoint.




> We get ALS on all calls, so it's the paramedic's decision as to when to fly. If I suggested taking the patient to Christina Hospital (closest trauma center) by ground, I'd bet you large sums of money that I'd be spending the call outside the ambulance. It's very ingrained in the culture here...and it makes sense why, from a selfish viewpoint. It's really easy to just wait around a few extra minutes for a helicopter and be done with it, as opposed to driving an hour yourself. This is helped by the fact that QA will probably jump on your *** for not following protocol with helicopter activation if you do take a trauma pt more then 30 minutes away by ground.



I have seen similar situations where helicopters have been launched for largely asymptomatic patients with severe MOI, and it's often seemed like the providers have had a vested in interest in not driving an hour to a trauma center.  Of course, it's still a bad practice.

Is it good? No. It's stupid. But until something changes, like usafmedic45 said, it's something I have to live with. At least until I graduate college and get back to PA.



> As for your comment about removing helicopter coverage for an area by tying it up with non-critical patients, almost everywhere in Maryland can get a helicopter in 20-25 minutes, even if the closest one is busy. Medivac coverage will never, ever be an issue in this state.



A lot of my experience comes from working in an area roughly the size of Texas with less than 4 million people, and two dedicated helicopters.  So the helicopter seems like a much more precious resource to me, because we just had one that could fly my local area, and it was often being utilised (unfortunately sometimes for less acute patients, or patients who could have gone by fixed wing or ground ALS), when a major trauma needed it.

As an outsider it seems like maybe you need less helicopters and more trauma centers, or more ground ALS, or even BLS transport?

Once again, sorry for giving you a hard time for something that's not your fault. All the best.


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## rescue1 (Dec 12, 2011)

Hey, no hard feelings. I could probably do better myself, and I'm glad EMTlife has shown me the light of better prehospital care.

Basically, everything you're saying is right, it's just that since most of the providers have been trained in Maryland and worked in Maryland all their life, they see no issue with it. The whole system is designed around the "helicopter to Shock Trauma" method of delivery, and it will be a while before it changes.
Until then, I can look forward to taking my paramedic outside Philly, where the protocols are nice and the trauma centers are reasonably close.


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