# Mess Ups..



## Ethanol4all (Apr 16, 2007)

...just a random question, but has anyone ever completely messed up on a call ? like, just blatantly misdiagnosed, mistreated, or even simply had no idea what was wrong and what you had to do..? ...sorry....EMT school's been kinda making me paranoid of approaching a victim, and just choking completely h34r:  :sad: :blush:


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## firecoins (Apr 16, 2007)

we don't diagnose so you can not mis diagnose.

I didn't do a complete physical assessment and major bruises were found on the patient's back.  The pt was disoriented and could not tell what was wrong.


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## FF/EMT Sam (Apr 16, 2007)

That's a normal fear, and all of us make mistakes (except for RidRyder, of course  ).  As long as you know your stuff and keep a level head in the midst of chaos, you'll be fine.


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## Epi-do (Apr 16, 2007)

Sam is right.  No one is right 100% of the time.  We have all made mistakes at one time or another.  Your fear is one that all of us have experienced at one time or another.  Stay calm, make sure you know your stuff, and don't be afraid to ask for help from others on the scene.  You will do just fine!


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## HorseHauler (Apr 16, 2007)

#1 on the list of pearls... 

*Always involve someone with deeper pockets...

When in doubt... call medical control


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## akflightmedic (Apr 16, 2007)

First, I have to disagree with the statement "we don't diagnose".

This is filled with complete ignorance if you believe that. You do make a diagnosis or you will never be able to do any treatment as you would not know what the problem is. The only caveat is our diagnosis may not be the same the ER comes up with, but it is the one we formed in the field to intiate treatment.

Another fine example of where education comes into play because if we truly understand A&P, amongst many other things, and eliminate the  "if we see this we do this" mentality, it is easy to form an educated diagnosis and render appropriate care.

Now for the question at hand.


We all make mistakes. We are pacticing medicine, emphasis on practicing.

Some mistakes are minute and some are fatal. Yes it happens and no the person who made the mistake does not always get caught or penalized. As you advance in your knowledge, situations will present themselves that may lead you to choose one out of several appropriate treatment modalities. You go with what you know and the person suffers. Were you wrong? Who knows, but you will second guess yourself for a long time and that is something you should not do. Discuss it afterwards, constructive criticism is fine, but do not leave your mind to always wonder what if you had done something else.

Freezing up on a call is normal as well but the way to avoid this is to be sound in your knowledge and confident within yourself. You may find yourself surprised at how quick you actually react to situations when you least expect it.


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## firecoins (Apr 16, 2007)

akflightmedic said:


> First, I have to disagree with the statement "we don't diagnose".
> 
> This is filled with complete ignorance if you believe that. You do make a diagnosis or you will never be able to do any treatment as you would not know what the problem is. The only caveat is our diagnosis may not be the same the ER comes up with, but it is the one we formed in the field to intiate treatment.
> 
> Another fine example of where education comes into play because if we truly understand A&P, amongst many other things, and eliminate the  "if we see this we do this" mentality, it is easy to form an educated diagnosis and render appropriate care.



wedo not diagnose because it is against New York State and National Standards for basics to do.  Our interventions on an EMT Basic level are opening airways, oxygen therapy, stoping external bleeding and stabalization.   In some cases we can give aspirin, epi-pens, abuterol and nitro depending on protocols and usually with permission from medical control who will make the diagnosis.  

Even if someone has an obvious broken arm we are not allowed to say they have a broken arm but we are allowed to splint the non broken, broken arm.


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## ffemt8978 (Apr 16, 2007)

firecoins said:


> wedo not diagnose because it is against New York State and National Standards for basics to do.  Our interventions on an EMT Basic level are opening airways, oxygen therapy, stoping external bleeding and stabalization.   In some cases we can give aspirin, epi-pens, abuterol and nitro depending on protocols and usually with permission from medical control who will make the diagnosis.
> 
> Even if someone has an obvious broken arm we are not allowed to say they have a broken arm but we are allowed to splint the non broken, broken arm.




You make an assessment, correct?  I hate to bust your bubble but assessing a patient's problem is essentially diagnosis - we just call it something else.


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## VentMedic (Apr 16, 2007)

akflightmedic said:


> First, I have to disagree with the statement "we don't diagnose".
> 
> This is filled with complete ignorance if you believe that. You do make a diagnosis or you will never be able to do any treatment as you would not know what the problem is. The only caveat is our diagnosis may not be the same the ER comes up with, but it is the one we formed in the field to intiate treatment.
> 
> Another fine example of where education comes into play because if we truly understand A&P, amongst many other things, and eliminate the  "if we see this we do this" mentality, it is easy to form an educated diagnosis and render appropriate care.



You might call it a "field diagnosis" which is appropriate in some circumstances. However, if called to give a legal deposition on your "diagnosis", it would be wise to stick with the DOT terminology of Assessment Based Management or Clinical Decision Making. Saying you diagnosed (even if your agency says you can) could bring another set of questions that you may not be prepared for.  Essentially that is what is also done in the ER initially until more definitive testing is done. Many disease processes have the same presentation but very different treatments. 

Making a "diagnosis" may skew your clinical judgement into trying to fit what you see into that "diagnosis". Thus, you may miss some very important information during your assessment.


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## firecoins (Apr 16, 2007)

ffemt8978 said:


> You make an assessment, correct?  I hate to bust your bubble but assessing a patient's problem is essentially diagnosis - we just call it something else.



I hate to burst your bubble but I am suppossed to assume the worst based on the nature of illness. That is not a diagnosis. I assume th worst and give interventions based on that assumption and what medical control says. 

If I could diagnose, half the people I backboarded wouldn't have been.


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## Ridryder911 (Apr 17, 2007)

That is why field care is changing, to rule out and prevent many from being CID and LSB. 

Clinical impression, field diagnosis is just wording semantics, like other profession other than physicians can diagnose as well. 

R/r 911


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## VentMedic (Apr 17, 2007)

Semantics can be scrutinized in the legal arena.

The term diagnosis is often overused and misunderstood.  Other health care professionals also make a "working" diagnosis based on their clinical assessment to follow certain protocols or clinical pathways. Their diagnoses are separate from a *medical* or *disease diagnosis*.  In many circumstances, without the additional diagnosic testing, the "educated diagnosis" is no more than an educated guess. You can see that from some of the different forums around the web. 

Example; The nursing diagnosis is a patient problem as identified by the nurse based on the nursing assessment. It is NOT a disease diagnosis. The terminology *nursing **diagnosis* is legally acceptable if the nurse is not making a medical/disease diagnosis or ordering care. Problems arise when the nurse fails to understand the difference and writes a medical diagnosis on a patient. 

CV nurses have advanced practice protocols but are doing clinical assessment and initiating their care pathways from that. They may have a "working" diagnosis in mind but are not making a medical diagnosis. 

Nurse Practitioners can make a diagnosis by ordering differential testing as needed. Their practice protocols must identify the area of practice to be performed by the nurse practitioner in collaboration with a physician. Collaborative practice arrangements are written agreements between the physician and NP.

Example: For Physical Therapists, it is the determination of the physical therapy diagnosis as well as recognition of clinical findings that would require referral to a medical care provider when the medical diagnosis (ie, diagnosis of the pathophysiologic condition) is in question. The Physical Therapist has a minimum of a graduate degree of at least a Masters, preferably Ph.d.

The same is true for the Speech and Occupational Therapists who have similar educational minimums.

For a good legal stand, choose your words carefully.


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## Ridryder911 (Apr 17, 2007)

I agree, even physicians have to word as such. My point though is that the word diagnosis can have more than one connotation and meaning. 

P.S. Not all states require Nurse Practitioners to be directly associated with physicians, in fact very few unlike PA's, since they work on their own license. In fact 16 states allow NP's to work free standing and as well have the ability to bill on the their own, without a physician oversight or participation and yes they too can as well legally medical diagnose as an advanced practitioner. This is reason I changed from PA program to a NP program. 

R/r 911


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## VentMedic (Apr 17, 2007)

Ridryder911 said:


> My point though is that the word diagnosis can have more than one connotation and meaning.



True, many diagnoses for both working and admitting are actually "symptoms" such as chest pain and shortness of breath. CHF or Pulmonary Edema can be used as a symptom and diagnosis. PNA, COPD and RAD (in children) are broad catch alls. Even the term ARDS is used in a broad sense and yet it is a specific diagnosis.  As you know from also being a Reg Nurse, we have changed the "wording" of our cardiac protocols several times over the past few years; R/O MI, Chest Pain, Acute Coronary Syndrome etc. 



Ridryder911 said:


> P.S. Not all states require Nurse Practitioners to be directly associated with physicians, in fact very few unlike PA's, since they work on their own license. In fact 16 states allow NP's to work free standing and as well have the ability to bill on the their own, without a physician oversight or participation and yes they too can as well legally medical diagnose as an advanced practitioner. R/r 911



It has helped also that NPs have increased their education level to Masters in many states. The quickie 6 mth programs after 1 year nursing experience that  Ohio State and Georgetown had weren't enough. It made people leary of giving them the indepence they have now. There are still several 1 yr and 18 mth certificate programs without the benefits of a Masters degree. The PA programs are also going to the Masters level in many states.  

The only point I was trying to get at; know your audience and choose your wording appropriately.


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## VentMedic (Apr 17, 2007)

Ethanol4all said:


> ...just a random question, but has anyone ever completely messed up on a call ? like, just blatantly misdiagnosed, mistreated, or even simply had no idea what was wrong and what you had to do..? ...sorry....EMT school's been kinda making me paranoid of approaching a victim, and just choking completely h34r:  :sad: :blush:



I guess the thread got a little side tracked. 

Probably everybody has choked on scene at least once in their career whether starting out or as an experienced provider.  Just when you think you've seen it all, you really haven't.  I am still amused, amazed and at times horrified by what I see.  The big thing about making a mistake is knowing you've made it. Then it can be corrected and something will be learned in the process. 

When approaching, make sure your safety is priority.

If the pt presents as a complex "who knows what's wrong", do your ABCs. Then, if the pt has his/her ABCs intact, you can take a deep breath and go on to do further assessment.  Treating what you can at the BLS level, monitor the vitals, re-assess as needed and relay to the hospital staff what you saw at scene, signs and symptoms as presented by the pt. and any changes.  Communicate/Listen to the patient. Hearing their voice tells you they are still ventilating and mentating to some degree. You will have a partner on the ambulance that can provide another set of eyes, ears and assessment. Don't get ahead of yourself.  The paranoid feeling will fade after you get hands on experience in the field and put the book learned skills to use. 

Most of the patients we get in the hospital, we just have to treat the signs and symptoms until more testing is done. Sometimes it might be days before we know the bug, disease or disorder we're dealing with. Much of the treatment is trying to stay ahead of things before something else falls apart on the patient.  It would be nice if all the ailments would fit neatly into the few disease processes learned in EMT or Paramedic school.

Relax, EMT will be a nice beginning for future endeavors. See it as a compliment to your other college work at UCLA. Developing good communication skills in both areas will enhance your career prospects.


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## Airwaygoddess (Apr 21, 2007)

Hi!  I know that being in a learning situation can be overwhelming but you have to remember one thing, no question is ever stupid, it is better to ask and get an answer then not to ask and do the "what if " dance.  Second, keep in your scope of practice.  Your instructor should have gone over this information and if items come up and do not make sense, ASK!  Last but not least, I'm going to give you a piece of advice that my mom passed on to me, and I have passed it along to students and brand new nurses along my way.
" It is always important to have just a little "healthy" fear, for your job. Because it teaches and reminds you to have the respest for your profession"
Keep on learning!


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## EMTBandit (Apr 21, 2007)

Everyone makes mistakes. It just a matter of learning from them instead of worrying about it. Like one night I made an embarrasing mistake on the radio, or at least I was just embarrased that I did it. But instead of worrying about it, I learned from it. Same goes for calls, if you think you did something wrong on a call, or didn't do it as efficiently as you would have liked, ask for help or just take a deep breath and slow it down a bit so your not as frightful. As was once said, The only thing we have to fear, is fear itself. Fear can be a good thing, as long as you learn from it and don't let it paralyze you.


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## mfrjason (Apr 23, 2007)

Even though people think we are computers,we're not,we do make mistakes.


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## firecoins (Apr 23, 2007)

No! My protocols say I am in fact a computer.


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## Jon (Apr 24, 2007)

you know.. we need to just start a "diagnose vs. don't diagniose" thread...

Anyway... We've all made mistakes at some point... the trick is to learn from them, so that you don't flub next time.


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## gradygirl (Apr 24, 2007)

We were dispatched to a pt having difficulty breathing. We get there and we find out pt sitting on a toilet. She's not having difficulty breathing, but is only able to say her birthdate, nothing else. AND she can't move her left arm. First thing we figure is that maybe she stroked out on the toilet, she was 70-something, so a CVA wasn't out of the question. We move her to the stretcher, but when my partner slides her hand out from where she had been holding the pt's left side, there was a liquid covering the glove, almost bloody, but not blood. We lift up the shirt and see sores, so now we have NO clue what's going on. We transport lights and sirens, simply because we have no idea what we're dealing with; our patch to the was so vague that they had no idea what they were to expect. While in the truck, we smell death, both of us are dry heaving for the entire ride. When we get to the ER and cut the pt's shirt off, we find a HUGE area of necrotic tissue, involving the pt's left breast and extending across her side to her back. It even when subcutaneously into her arm, destroying the limb. They figure that it was a cancer that was ignored, leading to the state we found her in.

So, moral of the story. Don't worry if you don't know or if your ideas about what the pt has chage, ours is an inexact science. We're not doctors, it's not our job to fully diagnose. And if you really don't know what's going on, drive fast or call for back up.


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## Ridryder911 (Apr 24, 2007)

Couple of things. Driving fast NEVER saves lives, rather endangers them! 
The fluid you were in contact probably was serosanguinous fluid from the necrosed tissue or else was from gangrene. One has to be careful on gaseous gangrene. Did you place BSI (gown, mask, eye wear on?)

Why did you not expose the patient and see what you had than rather "run" with them to the ER? If it was blood or a sucking chest wound, would you had found it? As well, where you not taught to "expose injuries" for examination?  Place sterile dressings on open wounds? 

You are right it is not an exact science, but it is a form of health care and part of our job and responsibility is to examine for wounds, treat appropriately and transport safely.. and what warranted L & S? 

I am sure it was smelly, most rotting tissue does.. but, that is part of the job.

Yes, ED has a responsibility, but so does EMS. 

R/r 911


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## gradygirl (Apr 24, 2007)

You're so very right, but ours was a slightly special situationl; we were less than a minute from the hospital, so we wanted to get her there rather than to stay and specifically diagnose everything. 
And what warranted L&S was the fact that, between myself, my partner, and a number of fire-medics on scene, our combined years of experience told us something was totally amiss and that this woman was in serious condition. She was actually taken to the OR immediately after we brought her in and I don't think she made it.


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## Guardian (Apr 24, 2007)

sucking chest wound can kill in a minute.


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## Guardian (Apr 24, 2007)

recognizing a condition like CVA and immediately transporting is good. 

Thinking something is beyond your capabilities and rushing to the hospital is never good.  EMS was invented to stop this practice.


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## MMiz (Apr 24, 2007)

Has anyone ever missed a pt's [SIZE=-1]fentanl patch[/SIZE]?  We did, and the hospital caught it during their initial intake exam.  Simply removing the patch seemed to solve a lot of problems.

Edit: Change nitro to [SIZE=-1]fentanyl.[/SIZE]


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## Guardian (Apr 25, 2007)

pinpoint pupils should give it away.


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## Jon (Apr 25, 2007)

Guardian said:


> recognizing a condition like CVA and immediately transporting is good.
> 
> Thinking something is beyond your capabilities and rushing to the hospital is never good.  EMS was invented to stop this practice.


I disagree...

Knowing something is beyond your capabilites and rushing to the hospital is how the American EMS system is supposed to work. European systems "stay and play" in the field, with an MD, for extended time periods, and do a decent amount of treat and release. We go to the ED. We don't play around with trauma patients in the field.. we get to a trauma center.

I would say that "I've got no freaking clue" shouldn't be used often... but in a case like this... where everyone was scratching their heads and wasn't sure what was going on... well... high-flow diesel is sometimes the only treatment modality that makes sense.


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## Guardian (Apr 25, 2007)

Jon said:


> I disagree...
> 
> Knowing something is beyond your capabilites and rushing to the hospital is how the American EMS system is supposed to work. European systems "stay and play" in the field, with an MD, for extended time periods, and do a decent amount of treat and release. We go to the ED. We don't play around with trauma patients in the field.. we get to a trauma center.
> 
> I would say that "I've got no freaking clue" shouldn't be used often... but in a case like this... where everyone was scratching their heads and wasn't sure what was going on... well... high-flow diesel is sometimes the only treatment modality that makes sense.




Here's a challenge, give me one example of something where I can't do a full assessment and stabilize (which is sometimes just ruling out life threats and/or preventing other injuries) in field and I'll reconsider your point.

Do we do a full assessment and stabilize trauma pts?...yes
Do we do a full assessment and stabilize flesh eating disease victims...yes


No matter how strange or weird a person's condition may be, we should always do a full systematic assessment and treat appropriately based on condition.  With the call TCERT described earlier, I would not have even gone emergent.

Nothing is beyond our capabilities to deal with and treat appropriately.


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## Jon (Apr 26, 2007)

Guardian said:


> Here's a challenge, give me one example of something where I can't do a full assessment and stabilize (which is sometimes just ruling out life threats and/or preventing other injuries) in field and I'll reconsider your point.
> 
> Do we do a full assessment and stabilize trauma pts?...yes
> Do we do a full assessment and stabilize flesh eating disease victims...yes
> ...


I agree that we should do a full assessment... TCERT didn't really do that.

However, what can be done prehosptially for a paitent like that, espicially at the BLS level? Nothing, really, except O2. The patient is in shock (septic shock) and is exhibiting an altered mental status. Yes... a full assesment should be conducted, and the patient should be rapidly transported to the closest appropriate facility (which is 1 minute away). Proximity of ED negates the need for prehospital ALS if not already onscene (because you can be in the ED before ALS gets set up).

However, what can BLS do for that patient? High-flow O2, assist respirations/cirulation if needed, control major bleeding if needed, bandage wounds if time permits, and do a decent assessment so that the ED has a decent picure on what 

And relistically, with that short a distance to the ED.... the lights aren't going to buy you any time... except for merging in and out of traffic... so I'd probably transport emergently just because the call meets ALS criteria and the hosptial is your nearest ALS.

I guess, Guardian, that we agree on this.... but our phrasing is different... I'm just saying that although we should do a full assesment... there are often things that are above our ability to fix, and that require transport.


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## gradygirl (Apr 26, 2007)

I guess I need to make something else clear. Every single one of our medic trucks were being used on an MVC turned MCI. We were told by dispatch when we were sent to the call that we had no ALS backup, and if our patient warranted advanced care, to take them immediately to the hospital.

As for L&S, Jon is exactly right in determining our use of emergency tactics; we weren't far away, but people ignore emergency vehicles in Hartford unless you have L&S, which is fine under normal circumstances, but ours were not. Fire even cleared the main intersections for us until we got closer to the ED.


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