# Anyone ever been denied an intubation during clinicals?



## 281mustang (Dec 12, 2011)

I was in an ER clinical a couple days ago when an ETOH female came into the ER for an MVC after she was driving on the wrong side of the road and ran head-on into a car sitting at a stop light. 

Her vitals were fine but she was extremely combative so the ER doc decided to just RSI her. While the Nurses were getting the meds I went up to the doc and asked if "she would mind if I intubated the pt" to which she responded "yes, I actually do mind" with an extremely condescending tone and immediately walked away. It's difficult to express verbal emotion via text but lets just say it was obvious by her tone that she resented the fact I even bothered to ask her. 

Maybe I'm just spoiled by the fact that the CRNA's I worked with in the OR were extremely helpful and went out of their way to teach as much as possible but I think denying a Medic student a shot at a tube is a load of crap, especially when I'm at the tail end of my clinicals and have another 4 left before I'm eligable to graduate.

This is the first time I've ever spoken with this specific doc but the Nurses all like me and I believe I've proven myself to be a quality student at this clinical site.

Does anyone has similar stories or opinions/conflicting views?


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## usafmedic45 (Dec 12, 2011)

Yeah...happens all the time.  It's not a big deal so if you have a problem with it the real issue here is your ability to attribute properly and to deal with things like a professional.


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## JPINFV (Dec 12, 2011)

Were you working with that physician during the shift or had you worked with her prior to that shift?


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## 281mustang (Dec 12, 2011)

usafmedic45 said:


> Yeah...happens all the time.  It's not a big deal so if you have a problem with it the real issue here is your ability to attribute properly and to deal with things like a professional.


 Eh, hearing that it's common practice makes me feel a little better about the situation. Although I wouldn't say I've been 'unprofessional', I haven't been rude or treated her differently since it all transpired. I'm not enthusiastic about it but my motivation for creating this thread was to hear how prevalent this is.


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## 281mustang (Dec 12, 2011)

JPINFV said:


> Were you working with that physician during the shift or had you worked with her prior to that shift?


 No and no, in all fairness she was clueless to my skill level or lack thereof.


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## bstone (Dec 12, 2011)

From time to time various docs and nurses in the ER where I did my Intermediate internship would try to exclude the Intermediate students from various cases. They claimed something like "this is a bad one" or "we need to handle this seriously". When I calmly and gently replied (after they had handled it) that I would be seeing these same situations in the field and needed to have this training and experience they would actually agree. A few of them even apologized and said something like "you're right, sorry".


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## JPINFV (Dec 12, 2011)

281mustang said:


> No and no, in all fairness she was clueless to my skill level or lack thereof.




...and this is why I don't see a problem with this during this procedure. Some random person comes up and asks to intubate? Err, the answer is most likely going to be "no."


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## Smash (Dec 12, 2011)

JPINFV said:


> ...and this is why I don't see a problem with this during this procedure. Some random person comes up and asks to intubate? Err, the answer is most likely going to be "no."



Exactly.  Without knowing you, your background, your training etc, it is a pretty big risk to let you crack on with the tube.


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## bstone (Dec 12, 2011)

Smash said:


> Exactly.  Without knowing you, your background, your training etc, it is a pretty big risk to let you crack on with the tube.



In _theory_ they have been informed that there are students in the ER and part of their duties is to teach. In practice they are often not told, or forget, or don't care.


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## Sodapop (Dec 12, 2011)

During my clinical time I never asked a doctor to do a procedure but I asked if I coukd observe a few times. Luckily our docs would ask me if I wanted to do procedures. I found being there asking them questions when it was appropriate and interacting with them that they became comfirtable and would include me in everything possible including tubes, meds pushes, cardiac and cva and codes. I had docs take me to ct scan with them on cva alerts and traumas and another that mafe sure I was included and taken to cath lab on a stemi. I did see the same docs deny others procedures and told them flat out they were not comfortable with them attempting. In one case the doc had never seen the student and another a dic asked a question the student could not answer that was pertinent to the procefure so he asked him to step back. Both were professional and completely understood. In two cases I had docs ask me if I wanted to intubate amd I said I would but that the ither student had not had an attempt yet and both times the doc let the othet student do the tube. Maybe I should have taken the added experience but I felt that others who had no experience might benefit more since I had one on nearly every shift.

Sent from my mobile on tap talk please excuse the typos


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## JPINFV (Dec 12, 2011)

bstone said:


> In _theory_ they have been informed that there are students in the ER and part of their duties is to teach. In practice they are often not told, or forget, or don't care.



So, at your service if one unit gets a student then all units are told about that specific student and the student's level just in case they encounter the student on a call? Furthermore, how many students are we talking about? If it's an academic center, the attending is already going to have the residents and medical students to look after, plus now any students from other health care programs? Now consider that many EMS programs attach their students to nurses and not physicians.


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## bstone (Dec 12, 2011)

JPINFV said:


> So, at your service if one unit gets a student then all units are told about that specific student and the student's level just in case they encounter the student on a call? Furthermore, how many students are we talking about? If it's an academic center, the attending is already going to have the residents and medical students to look after, plus now any students from other health care programs? Now consider that many EMS programs attach their students to nurses and not physicians.



I am not certain I understand any of your questions.


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## JPINFV (Dec 12, 2011)

Question 1:

Why should every physician be notified that a student is present in the emergency room?

Corollary 1: 

Does every ambulance crew at your service know about every student regardless of if the student is on that specific ambulance? 

Question 2:

Is it reasonable to expect physicians to track every student in the ED, even if the student's preceptor is someone else? 

Question 3:

How many students is it reasonable to have the attending track, given that in some centers, there's a relative high number of students when simply considering the residents and medical students.


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## bstone (Dec 12, 2011)

JPINFV said:


> Question 1:
> 
> Why should every physician be notified that a student is present in the emergency room?


I was told that ER docs are informed that the ER is used for training nurses and EMTs during the orientation of the ER docs. This is what I meant by they may not remember.



> Corollary 1:
> 
> Does every ambulance crew at your service know about every student regardless of if the student is on that specific ambulance?


Nope. I only know of students when they are on my bus.



> Question 2:
> 
> Is it reasonable to expect physicians to track every student in the ED, even if the student's preceptor is someone else?


Nope. The student needs to be present, ready, willing and able to participate in their training. If they are absent then they have no one to blame but themselves. 


> Question 3:
> 
> How many students is it reasonable to have the attending track, given that in some centers, there's a relative high number of students when simply considering the residents and medical students.


I don't think anyone is asking the attending to track a student. That would be ridiculous. They have been informed that the ER is used for formal training of EMTs and nurses and part of their duties is to teach.


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## RocketMedic (Dec 12, 2011)

Is it reasonable for a doctor at a teaching instiution to flatly deny a student relevent learning on the basis of an ego trip or a bad mood?


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## JPINFV (Dec 12, 2011)

Rocketmedic said:


> Is it reasonable for a doctor at a teaching instiution to flatly deny a student relevent learning on the basis of an ego trip or a bad mood?




No. 

Is it reasonable for a physician to deny a student the chance to perform a dangerous procedure when the physician has no clue about the capabilities and competency of the individual student?

Yes.


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## JPINFV (Dec 12, 2011)

bstone said:


> I don't think anyone is asking the attending to track a student. That would be ridiculous. They have been informed that the ER is used for formal training of EMTs and nurses and part of their duties is to teach.



...but that's the problem. If a student from another ambulance walked up to you and identified them as a paramedic student and asked to have access to your drug box, would you just hand over the drug box? If a student's first interaction with an individual physician is, "Hi, I'm a student, can I intubate?" then I find it reasonable to decline the student to intubate that specific patient. 


Of course this is also why I think EMS student need to be shadowing physicians in the ED and not nurses.


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## exodus (Dec 12, 2011)

The doctor may have wanted to exclude you from a procedure that may have not actually been indicated as well. Unless there was something else going on with the patient.


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## systemet (Dec 12, 2011)

JPINFV said:


> Of course this is also why I think EMS student need to be shadowing physicians in the ED and not nurses.



This ^

About 1000X.

RNs are fantastic, they are a wealth of knowledge, and see a volume of patients in the ER / ICU that most paramedics never approach in the street.  There is tons we can learn from them, and in an ideal world they'd be our healthcare brothers and sisters.  

But, there's so much more an MD can give a paramedic in terms of education about clinical decision making, and various technical procedures that aren't commonly performed by RNs in the hospital.


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## 281mustang (Dec 12, 2011)

JPINFV said:


> Of course this is also why I think EMS student need to be shadowing physicians in the ED and not nurses.


 That would be amazing and would make for better Medics across the board, but the extreme backlash that would ensue if that ever happend would terminate it immediately. 

I've met some great docs that were more than willing to help with anything, but most believe their time is too valuable to spend an extended period of time with an EMS student that has a miniscule amount of knowledge in comparison to them. Not to mention the fact that there are EMS students in ER's more often than not meaning they would spend most of their time on the clock with EMS students. I can only imagine their reaction to that scenario.



exodus said:


> The doctor may have wanted to exclude you from a procedure that may have not actually been indicated as well. Unless there was something else going on with the patient.


 Good point. The decision to RSI her was definitely in the patient's disinterest. 

While the Charge Nurse was drawing up the Succs I leaned over and asked "Are you all seriously going to RSI this lady?" to which he replied "Yep! This is why you never throw a fit in an ER!"


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## CANMAN (Dec 12, 2011)

[/QUOTE] While the Charge Nurse was drawing up the Succs I leaned over and asked "Are you all seriously going to RSI this lady?" to which he replied "Yep! This is why you never throw a fit in an ER!"[/QUOTE]

With your above comment I agree with others here in that your delivery is the issue.... You are a PARAMEDIC STUDENT and the way you have stated that you addressed the staff makes it seem like you are a "know it all" and questioning them. They, unlike yourself, have already finished education and achieved certification, licensure, etc. You my friend have not. 

With that being said they may have been performing a procedure that you do not agree with or understand but I tend to think its not your place to question, in a trauma bay, while the procedure is about to take place, their judgement. Others may disagree with me here but this is my opinion. They may have keyed in on other assessment clues etc that you did not pick up on and based on their assessment/knowledge the procedure may have been warrented. 

I think a more appropriate way to address with situation would be to pull the RN aside post-procedure and ask a question such as: "why did you guys decide to RSI this patient" and see what they say, you just may learn something. Also with the intubation issue, like USAF said it happens but if you can't professionally address the issue it will continue to happen to you. Next time you are at clinical make contact with the MD's working, inform them you are a paramedic student here for the day, how far you are in your program, what your looking to acheive for the day/learn and ask them if they would be willing to include you on any procedures or assessments they feel you would benefit from. I can 100% assure you better luck with this method, and before you get defensive re-read my entire post and realize I am trying to help you.... :beerchug:


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## Smash (Dec 12, 2011)

JPINFV said:


> Of course this is also why I think EMS student need to be shadowing physicians in the ED and not nurses.



Amen to that!  We were lucky, we stuck with one (sometimes 2) anaesthesiologists, or attendings or whatever depending on where we were.  We had very little to do with nurses which is entirely appropriate in my view.
That continues out in the real world too.  I don't hand over sick patients to nurses, I hand over to Doctors and will wait for one to be present until I give my report.  Unless of course they are well patients, but for sick ones it's the doctors I speak with.


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## 281mustang (Dec 12, 2011)

CANMAN13 said:


> 281mustang said:
> 
> 
> 
> ...


 The context of my question was asked more in an inquisitive mannor and lacked any real form of a "know it all" demeanor. I can see what you would imply from just reading the quote but that's not at all how it was asked of (I believe) interpreted.



CANMAN13 said:


> I think a more appropriate way to address with situation would be to pull the RN aside post-procedure and ask a question such as: "why did you guys decide to RSI this patient" and see what they say, you just may learn something.


 While we were in the CT control room I did ask another Nurse why she was RSI'd and was told it was common practice for this specific MD when they're screaming and won't calm down. She then went on about expaining how readily the other Physicians in the ER  intubate and what each requires from their patient's condition before they're willing to tube them.



			
				CANMAN13 said:
			
		

> Also with the intubation issue, like USAF said it happens but if you can't professionally address the issue it will continue to happen to you. Next time you are at clinical make contact with the MD's working, inform them you are a paramedic student here for the day, how far you are in your program, what your looking to acheive for the day/learn and ask them if they would be willing to include you on any procedures or assessments they feel you would benefit from. I can 100% assure you better luck with this method, and before you get defensive re-read my entire post and realize I am trying to help you.... :beerchug:


 I understand that, I'm not offended and appreciate the points you brought up.:beerchug:


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## bstone (Dec 12, 2011)

JPINFV said:


> ...but that's the problem. If a student from another ambulance walked up to you and identified them as a paramedic student and asked to have access to your drug box, would you just hand over the drug box? If a student's first interaction with an individual physician is, "Hi, I'm a student, can I intubate?" then I find it reasonable to decline the student to intubate that specific patient.
> 
> 
> Of course this is also why I think EMS student need to be shadowing physicians in the ED and not nurses.




I don't know about where you went to school but at the ER where I did my Intermediate training I had an official hospital polo shirt and an official hospital picture ID that identified me as an EMT-Intermediate Student. That way there was no confusion as to who or what I was.


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## JPINFV (Dec 12, 2011)

For EMT clinicals, white dress shirt, black slacks, and a little name tag.


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## RocketMedic (Dec 12, 2011)

Making the decision to RSI a combative patient with no medical need to intubate sounds a lot like a malpractice suit waiting to happen. Im not opposed to chemical sedation, but a full om RSI is not in the patients best interest. Sounds like that MD needs to get a stern talking to.


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## STXmedic (Dec 12, 2011)

I had an MD that was going to do that last night before I explained the patient to him. Apparently the nurse taking report considered uncooperative and combative the same thing...


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## usafmedic45 (Dec 12, 2011)

> Making the decision to RSI a combative patient with no medical need to intubate sounds a lot like a malpractice suit waiting to happen.



Only if something goes wrong and then only if someone on the staff rats the doc out.  Most people value their jobs too much to do something like that.  Besides, if nothing untoward happened to the patient and full RSI was used at least at a theoretical level there would be no demonstrable harm to the patient which is a necessary requirement for a malpractice lawsuit to be successful.  



> Sounds like that MD needs to get a stern talking to.



Of course, but that's assuming that what the OP is telling us is actually correct.  We are getting one side of the story here and admittedly from someone who got told 'no' to a request.  Let's not crucify the doc without some credible evidence to support the OP's claim.  For all we know, the patient had more going on than he was aware of and the doc was just being sarcastic in the comment allegedly made to the OP about "throwing a fit".


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## firetender (Dec 12, 2011)

Sodapop said:


> During my clinical time I never asked a doctor to do a procedure but I asked if I coukd observe a few times. Luckily our docs would ask me if I wanted to do procedures. I found being there asking them questions when it was appropriate and interacting with them that they became comfirtable and would include me in everything possible including tubes, meds pushes, cardiac and cva and codes.


 
This is all about taking the time and exercising the patience to form relationships with staff in the hospital. Not just the Docs but the RN's as well, who, once they're sure you're not a loose cannon, will vouch for you.

If you're serious about stepping in and getting hands-on experience then it serves you well to be available to assist at any level so that when the right time comes you are a known entity who is not a threat.

In a nutshell; Get Known!


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## the_negro_puppy (Dec 12, 2011)

I guess if the Doc didnt know you should would be hesitant to let you step up to the plate.

Then again, I bet if that same Doctor's mother was very sick or injured and needed intubation, she would hope/like a paramedic with experience intubating to drop the ETT.


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## RocketMedic (Dec 12, 2011)

usafmedic45 said:


> Only if something goes wrong and then only if someone on the staff rats the doc out.  Most people value their jobs too much to do something like that.  Besides, if nothing untoward happened to the patient and full RSI was used at least at a theoretical level there would be no demonstrable harm to the patient which is a necessary requirement for a malpractice lawsuit to be successful.
> 
> 
> 
> Of course, but that's assuming that what the OP is telling us is actually correct.  We are getting one side of the story here and admittedly from someone who got told 'no' to a request.  Let's not crucify the doc without some credible evidence to support the OP's claim.  For all we know, the patient had more going on than he was aware of and the doc was just being sarcastic in the comment allegedly made to the OP about "throwing a fit".



I'm in total agreement with you on the story- we don't have both sides, nor do we have the information. That being said, it is not appropriate for anyone, even a doctor, to be dropping/RSIing patients simply due to their behavior. If there's an actual problem, then it could be appropriate, but the thought of a self-important MD working an ER RSIing her misbehaving patients based solely on their behavior does scare me somewhat.

I'm not saying that it wasn't done _technically_ correctly, but even with experienced providers, there's always room for error. Taking that risk for no reason is no bueno.


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## Smash (Dec 12, 2011)

Rocketmedic40 said:


> I'm in total agreement with you on the story- we don't have both sides, nor do we have the information. That being said, it is not appropriate for anyone, even a doctor, to be dropping/RSIing patients simply due to their behavior. If there's an actual problem, then it could be appropriate, but the thought of a self-important MD working an ER RSIing her misbehaving patients based solely on their behavior does scare me somewhat.
> 
> I'm not saying that it wasn't done _technically_ correctly, but even with experienced providers, there's always room for error. Taking that risk for no reason is no bueno.



Notwithstanding the Doctor's aside to the nurse, which may have been tongue in cheek - we don't really have any context - we really have no idea what the thought process was.  Where is the line between "combative" because they are a drunken a-hole, and "combative" because they have run their car into someone else and have a closed head injury?  Perhaps this patient warranted a CT and the Doctor may have decided that unconscious was the best way to achieve that without putting the patient and staff at risk when she went to the Doughnut of Death.


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## 281mustang (Dec 13, 2011)

usafmedic45 said:


> Only if something goes wrong and then only if someone on the staff rats the doc out.  Most people value their jobs too much to do something like that.  Besides, if nothing untoward happened to the patient and full RSI was used at least at a theoretical level there would be no demonstrable harm to the patient which is a necessary requirement for a malpractice lawsuit to be successful.
> 
> 
> 
> Of course, but that's assuming that what the OP is telling us is actually correct.  We are getting one side of the story here and admittedly from someone who got told 'no' to a request.  Let's not crucify the doc without some credible evidence to support the OP's claim.  For all we know, the patient had more going on than he was aware of and the doc was just being sarcastic in the comment allegedly made to the OP about "throwing a fit".


 My reasoning for questioning the Nurse about RSI was to see if there was something that I was unaware of as I came in towards the latter part of the transfer and had nothing to go off other than her vitals and meds she was believed to be on. 

The Charge Nurse was the one that made the comment about the pt getting tubed because 'she was throwing a fit'. I know his personality/sense of humor pretty well and can gauge pretty well when he's being facetious. If you think I fabricated their comments to spite the doctor I really don't know what to tell you.

I didn't create this thread to flame an ER doc, I created it to see how prevelent these situations are.


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## bstone (Dec 13, 2011)

While riding my bike home from school this evening I was thinking about the EMT-Doc pairing in the ER. I very much agree. We are working under the doc's license and under the doc's direction.


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## 281mustang (Dec 13, 2011)

bstone said:


> While riding my bike home from school this evening I was thinking about the EMT-Doc pairing in the ER. I very much agree. We are working under the doc's license and under the doc's direction.


 Yep. Nurses are great, but they just don't have the "lets review the pt's S/S to attempt to diagnose this and see what treatment is required" approach to the situation that we need.


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## Smash (Dec 13, 2011)

281mustang said:


> My reasoning for questioning the Nurse about RSI was to see if there was something that I was unaware of as I came in towards the latter part of the transfer and had nothing to go off other than her vitals and meds she was believed to be on.
> 
> The Charge Nurse was the one that made the comment about the pt getting tubed because 'she was throwing a fit'. I know his personality/sense of humor pretty well and can gauge pretty well when he's being facetious. If you think I fabricated their comments to spite the doctor I really don't know what to tell you.
> 
> I didn't create this thread to flame an ER doc, I created it to see how prevelent these situations are.



I don't think usafmedic was trying to imply that you were fabricating anything, but obviously what you tell us is filtered through what you perceive, and in your above statement (coming in late etc) you demonstrate why this is an important point to consider.  What you as a medic student perceive may not be what I, usaf, the nurse, the doctor or someone else may perceive.  This is not intended as a slight on you, or to put down your intelligence or ability, it is merely the way the world is.


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## 281mustang (Dec 13, 2011)

Smash said:


> I don't think usafmedic was trying to imply that you were fabricating anything, but obviously what you tell us is filtered through what you perceive, and in your above statement (coming in late etc) you demonstrate why this is an important point to consider.  What you as a medic student perceive may not be what I, usaf, the nurse, the doctor or someone else may perceive.  This is not intended as a slight on you, or to put down your intelligence or ability, it is merely the way the world is.


 I'm not deneying the Physician obviously had a better idea of the pt's condition than myself. 

I had a hunch that everything wasn't on the up and up which was confirmed by two other Nurses. Is it possible neither had a full grasp of the situation and just assumed the worst? Absolutely. Just sharing what happend from what I saw on my side of the fence.


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## usalsfyre (Dec 13, 2011)

RSI'ing a combative patient who needs a CT scan to r/o head injury is entirely appropriate. It was very common practice at several trauma centers I've been around. A patient must be still to get a quality image. My wife who is a rad tech reports it's much safer for the patient and the staff for the patient to be intubated and vented than chemically snowed to the point they will lay still enough for a CT without a secure airway.


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## RocketMedic (Dec 13, 2011)

usalsfyre said:


> RSI'ing a combative patient who needs a CT scan to r/o head injury is entirely appropriate. It was very common practice at several trauma centers I've been around. A patient must be still to get a quality image. My wife who is a rad tech reports it's much safer for the patient and the staff for the patient to be intubated and vented than chemically snowed to the point they will lay still enough for a CT without a secure airway.



Once again, agreed, but this is assuming we have a closed head injury. From the op, thats a possibility. That buys a tube if true.
If, on the other hand, that doc is dropping people for being emotional, misbehavior, etc...no bueno.

Remember that physicians are not always right, or even on the right track, and neither are nurses or paramedics. If you see something off, ask. If you know somethings off, tell them about it repectfully. If that doc is a good one, theyll listen to you and cooperate. If theyre not, you might get reamed. If you get reamed, well, you know who not to see yourself.

Medicine isnt a cert contest.


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## usalsfyre (Dec 13, 2011)

I agree, but the OP described an ETOH female post head-on MVC presenting as combative. I saw nothing inappropriate there, rather I saw an OP that didn't understand the risk associated with not performing the procedure.

I've gone toe-to-toe with physicians and nurses over crappy medicine on more than one occasion. Agreed we can't knock people out over emotions or bad behavior...to a point. If they present a danger to themselves or others to the point the amount of chemical sedation required endangers their airway, they still buy a tube.

If anything I've seen far less inappropriate intubations by physicians than paramedics.


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## Flight-LP (Dec 13, 2011)

usalsfyre said:


> I agree, but the OP described an ETOH female post head-on MVC presenting as combative. I saw nothing inappropriate there, rather I saw an OP that didn't understand the risk associated with not performing the procedure.
> 
> I've gone toe-to-toe with physicians and nurses over crappy medicine on more than one occasion. Agreed we can't knock people out over emotions or bad behavior...to a point. If they present a danger to themselves or others to the point the amount of chemical sedation required endangers their airway, they still buy a tube.
> 
> If anything I've seen far less inappropriate intubations by physicians than paramedics.



+1

I am a firm believer in prophylactic RSI, especially with this particular presentation. An altered individual, regardless of origin (alcohol or CHI), that is acting inappropriate after being involved in a head on collision will be getting intubated until fully evaluated by a trauma team. I'm not even too concerned about the injury to self aspect, but they are not going to injure me, nor are they going to injure the rest of the crew. Our helicopter, our rules. If you don't want to play by them, you have analgesia, sedation, paralytics, and plastic coming your way. Period.

OP, it sounds as if there was some communication that was lost in translation. Regardless, you cannot allow the physician refusal to bother you. There are patients that are appropriate for you to practice on and there patients that are no appropriate for you to practice on. Perhaps the situation and severity of the patient were the determining factors here and not the perceived attitude of the physician?

I am curious though, a lot of the responses have hit on the point of who the student should be shadowing. Does your program not have a Paramedic preceptor that is with you in the ER? Most of the hospitals around Houston require it as part of the contractural agreement.


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## KellyBracket (Dec 13, 2011)

To the OP -

Next time you're in clinicals and you see a doctor make a thought-provoking decision, try to find the appropriate time to ask them about their decision-making at that moment. Probably far more important than learning the mechanical skill is learning to judge WHEN you should deploy a skill. So many factors... 

It's a great opportunity to initiate a dialogue with a doctor. Plus, it sends the message that you aren't just focused on "the tube," but that you are sincerely interested in their experience and viewpoint. Heck, _everyone_ likes to talk about themselves. It's also a great way to lay the groundwork for getting procedures in the future.

It's fine to ask an RN, but you are going to get an incomplete perspective from them, since they rarely have to make decisions about airway management. Just a different mindset, not bad. 

Clinicals are tough - hang in there!


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## Farmer2DO (Dec 14, 2011)

JPINFV said:


> Of course this is also why I think EMS student need to be shadowing physicians in the ED and not nurses.



They need to shadow both.  There are aspects of medicine that they will learn from each provider that the other can't teach them.

Sit a few shifts with a triage nurse, and you start to understand the method behind their madness.  When you are bringing a patient in, this will come in handy.

Nurses do a lot of things that paramedics need to be really proficient with.  IVs and medication administrations are at the top of the list, but you can put any skill in there.  A good nurse can also teach you a fair amount about sick patients.  One of the big reasons that paramedic students do hospital time is that they don't get the exposure to the volume of skills in the field.

Physicians have a different perspective, and one that we also need to understand.  At the program where I teach, most of the ED time performed by paramedic students is under the supervision of an RN.  But they also have 5 (I believe) shifts throughout the class where they are assigned to a specific, EMS oriented physician 1:1.  They round on interesting cases, they talk theory, they perform skills.  They are meant to be spaced out so that they can see them progress.  I think it actually works pretty well.

And FWIW, there are things to be learned from almost any medical provider, if a student wants to, other than RNs and physicians.  Some of the providers when I was a paramedic student that I happened to run across and were willing to teach were a couple PAs, a respiratory therapist, a pharmacist, and a CRNA.  I got a lot out of spending time with these particular people.


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## usafmedic45 (Dec 14, 2011)

I would second the suggestion of having the students work with the RTs.  Most of us genuinely like teaching especially when we don't get to do it that often.


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## socalmedic (Dec 14, 2011)

to the OP in the original poster. the hospital I did my clinicals at, a level 2 trauma center, had a standing policy that only the attending trauma surgeon or anesthesia or ED doc in the absence of either where the only people allowed to intubate traumas. so you may have been denied strictly because it is even more impairative that is is done right the first time. there are alot more complications to trauma than medical intubation. ie, deformed anatomy, secretions/blood/vomit, increased ICP in head injuries made worse during laryngoscopy. further I didnot meet a single doctor that would let me do anything like intubation or central line prior to watching me do other procedures first. 

I do feel that medic students need to learn from both RN and MD, I spent my first half of clinicals with the RNs then the second half with the MD. it gave my a well rounded education.


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## firemedic0227 (Dec 15, 2011)

I see a lot of these "Students" talking about following a DR around in the ED. When I did my clinical times I NEVER followed a DR around because they would give information that would be way over our head as a PARAMEDIC Student. Instead we were told to follow RN's and Paramedics around in the ED and I did ALL of my Clinical Times at Creighton University Medical Center which is a "teaching hospital" with a Level 1 Trauma Center with possibly one of the Best ED's in the entire midwest. We also did ALL of our Intubations in the OR where there are more Intubations to do and we didn't even do it with the DR's we did it with Nurse Anethesist (SP)


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## socalmedic (Dec 15, 2011)

arharris83 said:


> I see a lot of these "Students" talking about following a DR around in the ED. When I did my clinical times I NEVER followed a DR around because they would give information that would be way over our head as a PARAMEDIC Student. Instead we were told to follow RN's and Paramedics around in the ED and I did ALL of my Clinical Times at Creighton University Medical Center which is a "teaching hospital" with a Level 1 Trauma Center with possibly one of the Best ED's in the entire midwest. We also did ALL of our Intubations in the OR where there are more Intubations to do and we didn't even do it with the DR's we did it with Nurse Anethesist (SP)



so what your saying is that the doctors were trying to teach you...

*IT IS YOUR RESPONSIBILITY AS A STUDENT TO ASK FOR CLARIFICATION IF THE TOPIC IS OVER YOUR HEAD. * 

nobody is going to spoon feed you. as a paramedic you are responsible for interviewing your patient and developing a patient care plan which includes treatments to correct the problem or alleviate the symptoms, which is exactly what a doctor does. nurses do not, they carry out the doctors orders and take care of the patients basic needs.


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## usafmedic45 (Dec 15, 2011)

socalmedic said:


> so what your saying is that the doctors were trying to teach you...
> 
> *IT IS YOUR RESPONSIBILITY AS A STUDENT TO ASK FOR CLARIFICATION IF THE TOPIC IS OVER YOUR HEAD. *
> 
> nobody is going to spoon feed you. as a paramedic you are responsible for interviewing your patient and developing a patient care plan which includes treatments to correct the problem or alleviate the symptoms, which is exactly what a doctor does. nurses do not, they carry out the doctors orders and take care of the patients basic needs.



Thank you.  That would have sounded much nastier coming out from me.


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## usalsfyre (Dec 15, 2011)

arharris83 said:


> I see a lot of these "Students" talking about following a DR around in the ED. When I did my clinical times I NEVER followed a DR around because they would give information that would be way over our head as a PARAMEDIC Student. Instead we were told to follow RN's and Paramedics around in the ED and I did ALL of my Clinical Times at Creighton University Medical Center which is a "teaching hospital" with a Level 1 Trauma Center with possibly one of the Best ED's in the entire midwest. We also did ALL of our Intubations in the OR where there are more Intubations to do and we didn't even do it with the DR's we did it with Nurse Anethesist (SP)



Your basically saying your not smart enough to understand advanced assessment.

Way to advance paramedic education there. Which FD or low level private do you want to work for?


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## Veneficus (Dec 15, 2011)

arharris83 said:


> I see a lot of these "Students" talking about following a DR around in the ED. When I did my clinical times I NEVER followed a DR around because they would give information that would be way over our head as a PARAMEDIC Student. Instead we were told to follow RN's and Paramedics around in the ED and I did ALL of my Clinical Times at Creighton University Medical Center which is a "teaching hospital" with a Level 1 Trauma Center with possibly one of the Best ED's in the entire midwest. We also did ALL of our Intubations in the OR where there are more Intubations to do and we didn't even do it with the DR's we did it with Nurse Anethesist (SP)



???

You are telling me that a doctor cannot give you information that is usable to your career and practice?

That sounds to me like a failure of the doctor.

Since the original founding of medicine in ancient times, doctors have been instructing non medical providers in health knowledge and practice.

Any doctor should be able to teach a patient with no medical background and even the most minimal of education how to apply home treatments and make better choices regarding their health. 

If they can't... well... They may have a medical degree, but they are not doctors.


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## EMTBHillbilly (Dec 15, 2011)

Well imagine that:  an MD acting like an arrogant snob wad.  Who would have ever thought. . . forget about it and move on.  oh, and get used to it.  
Yea, it's frustrating dealing with doctors and nurses who have no clue what it's like outside their little world, but you've got to learn to deal with it without letting it get to you.  It's not about you, it's about them and their bs and insecurities.


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## JPINFV (Dec 15, 2011)

EMTBHillbilly said:


> Well imagine that:  an MD acting like an arrogant snob wad.  Who would have ever thought. . . forget about it and move on.  oh, and get used to it.
> Yea, it's frustrating dealing with doctors and nurses who have no clue what it's like outside their little world, but you've got to learn to deal with it without letting it get to you.  It's not about you, it's about them and their bs and insecurities.




I could have so much fun with this post... I really could. After all, imagine that, an EMT with a chip on his shoulders.


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## usalsfyre (Dec 15, 2011)

EMTBHillbilly said:


> Well imagine that:  an MD acting like an arrogant snob wad.  Who would have ever thought. . . forget about it and move on.  oh, and get used to it.
> Yea, it's frustrating dealing with doctors and nurses who have no clue what it's like outside their little world, but you've got to learn to deal with it without letting it get to you.  It's not about you, it's about them and their bs and insecurities.



Hmmm, considering the OP was asking a physician he'd had no interaction with to perform a dangerous and possibly difficult procedure I'd say it was less "arrogant snobwad" and more "prudent clinician" I'd have done exactly the same thing. Guess I'm an arrogant snobwad...


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## Shishkabob (Dec 15, 2011)

usalsfyre said:


> Guess I'm an arrogant snobwad...



Well......


h34r:


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## EMTBHillbilly (Dec 15, 2011)

JPINFV said:


> I could have so much fun with this post... I really could. After all, imagine that, an EMT with a chip on his shoulders.



Please, have fun.  I sure don't take this stuff personal or care what some anonymous person thinks.

I only deal with reality.  

1.  The response and reaction that is the topic of this thread was arrogant and snotty.  '"yes, as a matter of fact I do mind" and then walks away.'

2.  Any EMT needs to learn to deal with that type of attitude from doctors and nurses with a smile.  Most doctors and nurses are decent and helpful and treat us as fellow healthcare professionals with our own niche that overlaps theirs, but there is also the group that will inevitably treat the EMT like an ambulance driver who isn't worthy of their time and can offer them nothing in the chain of patient care.


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## JPINFV (Dec 15, 2011)

EMTBHillbilly said:


> 1.  The response and reaction that is the topic of this thread was arrogant and snotty.  '"yes, as a matter of fact I do mind" and then walks away.'



I'll pose the question again. You're on scene. An EMT student from a different ambulance on scene approaches you and asks if he can do a high risk procedure. Do you just let someone you don't know do a high risk procedure? 



> 2.  Any EMT needs to learn to deal with that type of attitude from doctors and nurses with a smile.  Most doctors and nurses are decent and helpful and treat us as fellow healthcare professionals with our own niche that overlaps theirs, but there is also the group that will inevitably treat the EMT like an ambulance driver who isn't worthy of their time and can offer them nothing in the chain of patient care.



I agree, however this has nothing to do with comments like, "Outside their little world" or "insecurities." I've seen more "little worlds" and "insecurities" from EMS providers than I have from physicians. Want to see "insecurity"? Look at the comments on Facebook when ever someone links to Kelly Grayson's "Day in the Life of an Ambulance Driver" blog.


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## Shishkabob (Dec 15, 2011)

JPINFV said:


> Do you just let someone you don't know do a high risk procedure?



Devils advocate...


Don't our patients let us everyday?


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## Smash (Dec 15, 2011)

Linuss said:


> Devils advocate...
> 
> 
> Don't our patients let us everyday?



They either don't have the choice and there is implied consent, or they do and you gain informed consent.

Completely different scenario from the one posted.


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## socalmedic (Dec 15, 2011)

Linuss said:


> Devils advocate...
> 
> 
> Don't our patients let us everyday?



by virtue of me arriving in a marked ambulance and in an authoritative uniform exuding self confidence, our patient feel confidant that I know what I am doing. they feel safe in the fact that I have passed my training.

put me and a student in the same uniform and put us in front of the same patient and i can almost guarantee they will know off the bat who the student is.


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## firemedic0227 (Dec 15, 2011)

Let me clear up what I was trying to say. I was just trying to say as a PARAMEDIC STUDENT, we were told to stick to a Register Nurse or the Paramedic that was working the ED at the time because we could closely correlate what we were learning in class to what they could teach us vs a DR. Yes Dr's know a lot and are a great bed of information at ADVANCED MEDICAL ISSUES, not necessarily the best for a PARAMEDIC STUDENT. I can tell you from personal experience (having a DR teach my Paramedic Class) there were lots of times that he spoke over our heads as PARAMEDIC STUDENTS that not only myself but my classmates needed clarification on. We had adjunct faculty that have been medics for 10+ years in the field that didn't know certain things that the DR that was teaching our class was talking about. As a PARAMEDIC STUDENT you need to learn the basics of being a PARAMEDIC not a Medical Student, after all if I wanted to go to school to be a DR I would have been a Medical Student not a Paramedic Student. With that said yes ED Docs and Docs over all are an awesome bed of information but not for someone just starting out in the field. I learned more from the Paramedics on the Ambulances than I did probably from any DR because they seemed to talk over our heads as Paramedic Students.


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## EMTBHillbilly (Dec 15, 2011)

JPINFV said:


> I'll pose the question again. You're on scene. An EMT student from a different ambulance on scene approaches you and asks if he can do a high risk procedure. Do you just let someone you don't know do a high risk procedure?
> 
> 
> 
> I agree, however this has nothing to do with comments like, "Outside their little world" or "insecurities." I've seen more "little worlds" and "insecurities" from EMS providers than I have from physicians. Want to see "insecurity"? Look at the comments on Facebook when ever someone links to Kelly Grayson's "Day in the Life of an Ambulance Driver" blog.



Of course you don't and I'm not arguing what the doctor intended, it was the way it was done in an arrogant, snotty manner.  Again "yes I do mind" and then walks away.  It's so easy to be nice when you are talking to someone in a professional situation rather than being harsh and insensitive.

I'm also not arguing that paramedics aren't that way.  They are some of the most insecure people with working class chips on their shoulders that I've ever worked with. . . but that's not the topic here.  The topic was to give the paramedic student input about the snide remark he received from a doctor.
Follow along.

As for "little world."  The hospital is a little world.  It all happens inside one place.  In EMS we deal with the whole rest of the world outside the hospital.  It's a big place with a lot of crazy situations.  we don't have millions of dollars worth of equipment, security and a team of experts in every body system behind us.
g'night.


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## usalsfyre (Dec 15, 2011)

arharris83 said:


> Let me clear up what I was trying to say. I was just trying to say as a PARAMEDIC STUDENT, we were told to stick to a Register Nurse or the Paramedic that was working the ED at the time because we could closely correlate what we were learning in class to what they could teach us vs a DR. Yes Dr's know a lot and are a great bed of information at ADVANCED MEDICAL ISSUES, not necessarily the best for a PARAMEDIC STUDENT. I can tell you from personal experience (having a DR teach my Paramedic Class) there were lots of times that he spoke over our heads as PARAMEDIC STUDENTS that not only myself but my classmates needed clarification on. We had adjunct faculty that have been medics for 10+ years in the field that didn't know certain things that the DR that was teaching our class was talking about. As a PARAMEDIC STUDENT you need to learn the basics of being a PARAMEDIC not a Medical Student, after all if I wanted to go to school to be a DR I would have been a Medical Student not a Paramedic Student. With that said yes ED Docs and Docs over all are an awesome bed of information but not for someone just starting out in the field. I learned more from the Paramedics on the Ambulances than I did probably from any DR because they seemed to talk over our heads as Paramedic Students.



Crawfishing doesn't get you anywhere.

Our job is very, very dissimilar from ED or med surg nursing. It's far closer to a mid-level (NP or PA) or physician. If it's over your head, perhaps it's time you up the level of your head.

As far as the 10+ year medics being lost? I'm not surprised. Homeostasing for 10 years with a patch on your arm doesn't mean a whole lot.


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## socalmedic (Dec 15, 2011)

arharris83 said:


> Let me clear up what I was trying to say. I was just trying to say as a PARAMEDIC STUDENT, we were told to stick to a Register Nurse or the Paramedic that was working the ED at the time because we could closely correlate what we were learning in class to what they could teach us vs a DR. Yes Dr's know a lot and are a great bed of information at ADVANCED MEDICAL ISSUES, not necessarily the best for a PARAMEDIC STUDENT. I can tell you from personal experience (having a DR teach my Paramedic Class) there were lots of times that he spoke over our heads as PARAMEDIC STUDENTS that not only myself but my classmates needed clarification on. We had adjunct faculty that have been medics for 10+ years in the field that didn't know certain things that the DR that was teaching our class was talking about. As a PARAMEDIC STUDENT you need to learn the basics of being a PARAMEDIC not a Medical Student, after all if I wanted to go to school to be a DR I would have been a Medical Student not a Paramedic Student. With that said yes ED Docs and Docs over all are an awesome bed of information but not for someone just starting out in the field. I learned more from the Paramedics on the Ambulances than I did probably from any DR because they seemed to talk over our heads as Paramedic Students.



so in summary, you walked around all day starting IVs and doing 12 lead ECGs. you did this because someone else told you that you dont need to know about the "advanced medical issues" like when CPAP is appropriate verses RSI. or lasix isnt the best treatment for this patient with CHF... 

your saying that the MD teaching your class was teaching you to one level but the "ancillary instructors" are telling you that being sub par is OK because they are too lazy to learn it as well. this attitude is why we cant make any advancements. we have too many people who are lazy and settle for just enough. you are being lazy by not going forth and asking for clarification. you are lazy for not trying to be the best you can be. I do not want you or anyone like you ever touching me or my family. Please do us all a favor and either give paramedic school everything you have or dont finish. if this hurts your feelings it should. I tried being nice in the beginning but it obviously didnt work. 

I hope you know that sometime in your first year on your own there will be a call which makes you question why you are a paramedic, you will watch someone die and have no idea what to do or you are going to do something that speed up the process. I hope you think back to this.

moderators, I tried to be nice at first but I couldnt stand by idly and let this attitude go un-checked.


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## EMTBHillbilly (Dec 15, 2011)

You guys are rough, but I agree.  The more you learn about the body and it's various states, the better you will be as a medic.  If the instructor is teaching over your head, you're lucky.  Resources are easily acquired these days.  Use them and get the information you need to understand this instructor.


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## EMTBHillbilly (Dec 15, 2011)

"As a PARAMEDIC STUDENT you need to learn the basics of being a PARAMEDIC not a Medical Student"

I'm thinking that if you work as an EMT-B for a while before going to medic school, you'll know the basics.


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## Handsome Robb (Dec 15, 2011)

EMTBHillbilly said:


> "As a PARAMEDIC STUDENT you need to learn the basics of being a PARAMEDIC not a Medical Student"
> 
> I'm thinking that if you work as an EMT-B for a while before going to medic school, you'll know the basics.



Fair argument. However I never worked as an EMT on an ambulance and would like to think I have the basics down pretty well. 

I did work in an EMT capacity in other work environments though. 

It sucks you got denied a tube but like everyone said, you had built absolutely no report with that MD, I completely understand why she did what she did. Could she have had more tact? Probably but again we don't have both sides to this story. When you're upset often times you hear inflections in statements that you don't like because of the simple fact that you are unhappy about what is being said to you.


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## Smash (Dec 15, 2011)

As a paramedic student, you need to learn the art and science of practising medicine.  Who better to teach that than Doctors?


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## Handsome Robb (Dec 15, 2011)

Smash said:


> As a paramedic student, you need to learn the art and science of practising medicine.  Who better to teach that than Doctors?



Quoted for truth.


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## RocketMedic (Dec 15, 2011)

Agreed, with a caveat.

In the military, I've seen a lot of 'new' doctors. Clinicians with little business in emergency medicine thrust into it. I've been blessed by not having to deal with the stereotypical horrible Army docs, and our unit's never been seriously challenged by casualties. Yes, they are fountains of knowledge, and yes, they do usually like to teach. However, sometimes I find that we need to remind them what's relevant to the task at hand. This isn't the mark of a bad clinician, its the mark of an inexperienced clinician.

As paramedics, we have a role. As students, we need to understand that role well enough to do it on our own. There are some advanced topics that are not well grasped at 2am in an ER if poorly taught, but we do need to be able to take that bit of knowledge, research it, and learn.

If your instructor (be they paramedic, CNA, nurse, RT, or MD) tells you something and you don't understand, tell them. If you still don't get it, take more notes and study it.


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## Shishkabob (Dec 15, 2011)

Smash said:


> They either don't have the choice and there is implied consent, or they do and you gain informed consent.
> 
> Completely different scenario from the one posted.



Point still stands.


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## mycrofft (Dec 15, 2011)

*5=4*

:deadhorse:


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## firemedic0227 (Dec 16, 2011)

Trust me I have a thick skin, I have been out of Medic School since last month and I continue to study up on things that I am not really all the great at yet. With that said If I had questions I asked them or I find them out by getting into books and asking people like yourselves for input. I didn't have any EMT-B experience due to a DUI that I had almost 4 years ago and couldn't get a job, but I do feel as if my Basic Skills are pretty darn good without having been on an ambulance. I appreciate everything you guys do and everything you say to me on here it makes a better "medic" down the road. I was taught in my class differently from others have and that's whats wrong with classes there is no set standard on how to teach these classes. And no I didn't just go around and start IV's and do 12 Leads, I asked questions pushed Meds and if I didn't know how one worked or didn't know the dose I asked and told whoever I was following around I didn't feel comfortable about giving/doing something. I have already witnessed Death and dying in the field as a Ride A Long without any experience. I saw people murdered people dead from natural causes and Codes that ended up dying and I felt hopeless and all of those cases still bother me to this day.


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## MNRescue (Dec 16, 2011)

*Skill Denial*

I can feel your pain, at least as a student you can expect douche docs like that. What happened to me, I was working as an EMT in the ER, as in I was a paid employee. We had a peds case come in with a fx'ed femur. As we all know, you put the leg into traction. This particular doc (fresh out of residency) wanted to transport the child handing weights off the end of the stretcher (we didn't have a peds unit, as the Children's Hospital was only five minutes away). I suggested to the doc a way to provide traction that would not move. Field traction using cravats and a cane. Would have made the trip to the Children's Hospital in which they could then put the leg into hare traction there. Or even hang weights. She totally blew me off and acted like I didn't know Sh**. The child waited 4 hours for the Ambulance Supervisor to come and deliver a peds traction device. The time it took the Supervisor to get the device there, she could have been out of surgery and recovering.


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## Veneficus (Dec 16, 2011)

arharris83 said:


> Let me clear up what I was trying to say. I was just trying to say as a PARAMEDIC STUDENT, we were told to stick to a Register Nurse or the Paramedic that was working the ED at the time because we could closely correlate what we were learning in class to what they could teach us vs a DR. Yes Dr's know a lot and are a great bed of information at ADVANCED MEDICAL ISSUES, not necessarily the best for a PARAMEDIC STUDENT.




I would just like to address this on several levels.

I doubt the RN or Medic in the ED is a better source of information for correlating what you learned in class. 

One of the aspects of medical education is understanding “why.” I can say in my nearly 9 years of teaching medic class, less than 1% of all instructors I have ever met understand why beyond a few bullet points in the paramedic text.

The knowledge “why” helps you make better decisions about what treatments you choose for your patients as a paramedic. It also allows you to know what is going to come after your care, so you can set your patients up for success. 

Perhaps the greatest information you can gain from following the doctor is thought process and critical reasoning. 

Yet another benefit is learning how to differentiate what the most acute issue of a patient with multiple chronic pathologies.  (aka, is one making the others worse, is it unrelated, or are the sum total effects of the other pathologies causing an acute issue?) Don’t you think in the modern world where people are not only living longer, but more active longer, with multifactorial causes of long term pathology starting prior to birth, that kind of information would be absolutely critical to your function?

But now I ask you to help me. 

What is an advanced medical issue exactly? I have heard of complex ones, but never an advanced one. I would just offer what I can tell you about shock would probably make your head explode. Most doctors I know cannot reconcile the required balance of NF kB promotion of antiapoptosis, proinflammatory, and prothrombotic, effects in a clinical or lab environment.   Do paramedics not treat shock? Do you think the information I described doesn’t directly apply to you?

If you think it doesn’t, you are wrong and your patients can suffer, even die from your lack of understanding.




arharris83 said:


> I can tell you from personal experience (having a DR teach my Paramedic Class) there were lots of times that he spoke over our heads as PARAMEDIC STUDENTS that not only myself but my classmates needed clarification on. We had adjunct faculty that have been medics for 10+ years in the field that didn't know certain things that the DR that was teaching our class was talking about.



I will give you a break on this one for a couple of reasons. 

You don’t know any better and doctors who by their very nature spent almost all of their waking hours in medicine sometimes forget other people don’t. They can easily assume that things they consider common knowledge or obvious that others do as well. That is the fault of the doctor and she should seek to remedy it.

As for your adjunct instructors, I am embarrassed for them. They are supposed to be experts at prehospital medicine and after 10+ years of experience and continuing education, they should be on par with just about any physician (I will accept there are some really exception physicians whom nobody will be able to match wits with, but they are few.) discussing the concepts of such.



arharris83 said:


> As a PARAMEDIC STUDENT you need to learn the basics of being a PARAMEDIC not a Medical Student,



Could you tell me what the differences are?

I am not  smart enough to figure the differences out on my own.




arharris83 said:


> after all if I wanted to go to school to be a DR I would have been a Medical Student not a Paramedic Student. With that said yes ED Docs and Docs over all are an awesome bed of information but not for someone just starting out in the field.




Let me help you since you may not have understood my original comment.

If a doctor can, and everyday, educate patients with no medical accumen at all, surely they could teach you something useful to your job.




arharris83 said:


> I learned more from the Paramedics on the Ambulances than I did probably from any DR because they seemed to talk over our heads as Paramedic Students.



I would say because the doctors were treating you like a capable professional and trying to discuss things with you as a peer.

Clearly from your statements here, they gave you and your adjunct instructors far more credit than you have earned.

I think it is probably better if the guys in your area just stick with driving the ambulance and stop "teaching".


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## Veneficus (Dec 16, 2011)

MNRescue said:


> I can feel your pain, at least as a student you can expect douche docs like that. What happened to me, I was working as an EMT in the ER, as in I was a paid employee. We had a peds case come in with a fx'ed femur. As we all know, you put the leg into traction. This particular doc (fresh out of residency) wanted to transport the child handing weights off the end of the stretcher (we didn't have a peds unit, as the Children's Hospital was only five minutes away). I suggested to the doc a way to provide traction that would not move. Field traction using cravats and a cane. Would have made the trip to the Children's Hospital in which they could then put the leg into hare traction there. Or even hang weights. *She totally blew me off and acted like I didn't know Sh**.* The child waited 4 hours for the Ambulance Supervisor to come and deliver a peds traction device. The time it took the Supervisor to get the device there, she could have been out of surgery and recovering.



:rofl:

Sorry, but that doc was right.


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## MNRescue (Dec 16, 2011)

Veneficus said:


> :rofl:
> 
> Sorry, but that doc was right.



Would you like to ride in the back of an ambulance with a broken femur with 20 lb weights bouncing up and down over every bump not to mention the risk of a severed artery? And in regards to the wait time, how do you make a 3yr old child wait that long, sedate them? That opens a whole new can of worms as well, especially considering the lack of any peds experts onsite. BTW, it took my complaining to the Charge Nurse to stop the doc from wanting to transport. I guess better to wait four hours than have weights bouncing.


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## Veneficus (Dec 16, 2011)

*I accept your challenge*



MNRescue said:


> Would you like to ride in the back of an ambulance with a broken femur with 20 lb weights bouncing up and down over every bump not to mention the risk of a severed artery? And in regards to the wait time, how do you make a 3yr old child wait that long, sedate them? That opens a whole new can of worms as well, especially considering the lack of any peds experts onsite. BTW, it took my complaining to the Charge Nurse to stop the doc from wanting to transport. I guess better to wait four hours than have weights bouncing.




The purpose of applying traction is to elongate the distance between the opposing ends of the fracture to mitigate the pain and other injurious complications when the musculature of the proximal lower limb contract and “over approximate.” 

The reason it is the treatment of choice for the femur is because the fracture cannot be immobilized in the acetabular joint. (allowing the joint above and below to be splinted)

Weights were the method of choice before traction splints were developed. (more useless EMS gadgets) With external fixation being the alternative. 

As long as the weights are secured from swinging or overly bouncing around (like setting them on the ambulance floor and driving slowly and carefully or simply tying them under tension to the stretcher) they would work fine.

Moreover, if you actually understand the principles of  lower limb anatomy and orthopaedic pathology, you can apply traction with a simple roll of gauze or triangular bandage and secure it under tension to the bottom of the stretcher.

The waiting/suffering the child did was because of the insistence on the use of the manufactured traction device by a provider who didn’t understand traction.


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## usalsfyre (Dec 16, 2011)

MNRescue said:


> Would you like to ride in the back of an ambulance with a broken femur with 20 lb weights bouncing up and down over every bump not to mention the risk of a severed artery? And in regards to the wait time, how do you make a 3yr old child wait that long, sedate them? That opens a whole new can of worms as well, especially considering the lack of any peds experts onsite. BTW, it took my complaining to the Charge Nurse to stop the doc from wanting to transport. I guess better to wait four hours than have weights bouncing.



Which was it, a horrible, dangerous, long, bouncy transport? Or a five minute ride? 

How about securing the weights to the stretcher with the cravats so they didn't bounce and swing?

The big place where paramedics have an independent body of knowledge is the transport aspect of medicine. In this case, you failed in that regard.


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## MNRescue (Dec 16, 2011)

Veneficus said:


> The purpose of applying traction is to elongate the distance between the opposing ends of the fracture to mitigate the pain and other injurious complications when the musculature of the proximal lower limb contract and “over approximate.”
> 
> The reason it is the treatment of choice for the femur is because the fracture cannot be immobilized in the acetabular joint. (allowing the joint above and below to be splinted)
> 
> ...


That's the point I was trying to make, the fact that this Doc wanted to hang weights without knowing that the slower routes were the most unstable roads. We are known for our pot holes in MN. Short of air lifting the child for a 10 mile ride distance. (BTW, I worked in house, not the street and the crew that originally was to transport didn't give much feedback either.)


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## RocketMedic (Dec 16, 2011)

From my perspective, I'd pick a tied or 'field' traction splint over weights any time. I can control tension a lot more easily with a traction splint (manufactured or improvised) then I can with weights.

Keep it simple. Applies to a lot of stuff.


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## Veneficus (Dec 16, 2011)

Rocketmedic40 said:


> From my perspective, I'd pick a tied or 'field' traction splint over weights any time. I can control tension a lot more easily with a traction splint (manufactured or improvised) then I can with weights.
> 
> Keep it simple. Applies to a lot of stuff.



I like improvised with kling best. (rolled gauze) I appreciate having as few working parts as possible.

I don't like carrying heavy gear that rusts or has only one purpose.


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## RocketMedic (Dec 17, 2011)

I really can't think of a great reason to use weighted splints for patient movement. That is not a good doctor decision.


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## MedicPatriot (Dec 18, 2011)

Haha YES I had this happen quite often in my clinicals. A few doctors let me, a few didn't. I was a bystander on a 3 mo. old SIDS arrest and I asked the medic if I could get the tube (a preceptor I knew was on board). Just today I asked an ER doc if I could intubate after he did the RSI, and I'm an EMT-P done with clinicals. You have to get/retain the skills somehow, its not like we do it every day.


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## usafmedic45 (Dec 18, 2011)

> I was a bystander on a 3 mo. old SIDS arrest



There is no reason we should be referring to a pediatric arrest as a "SIDS arrest".  It's not SIDS until the pathologist has ruled out all causes of arrest.   Most of them of what used to be classified as SIDS (you very seldom ever see it used anymore; most of them are just put down as "cause undetermined") are simply suffocation deaths because they parents are stupid enough to put the kid face down.  "SIDS" is just a cop out and a way of making parents not feel so bad about effectively having killed their child.  A lot of them should be rotting in jail for negligent homicide if you ask me.


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## Veneficus (Dec 18, 2011)

usafmedic45 said:


> There is no reason we should be referring to a pediatric arrest as a "SIDS arrest".  It's not SIDS until the pathologist has ruled out all causes of arrest.



Or until the doc signs it on the death certificate on a patient not going to autopsy in order to save a family that made a terrible mistake because they didn't know any better from criminal prosecution.


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## MedicPatriot (Dec 18, 2011)

usafmedic45 said:


> There is no reason we should be referring to a pediatric arrest as a "SIDS arrest".  It's not SIDS until the pathologist has ruled out all causes of arrest.   Most of them of what used to be classified as SIDS (you very seldom ever see it used anymore; most of them are just put down as "cause undetermined") are simply suffocation deaths because they parents are stupid enough to put the kid face down.  "SIDS" is just a cop out and a way of making parents not feel so bad about effectively having killed their child.  A lot of them should be rotting in jail for negligent homicide if you ask me.



Well our protocols actually have a "SIDS" category in which this patient falls into so that's how I worded it.

You are right though, I have an inkling the mother rolled over on the baby in her sleep but that's just my thoughts. 

Being flagged down for "the baby fell out" wasn't exactly what my vocabulary thought it would be.


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## usafmedic45 (Dec 18, 2011)

> Or until the doc signs it on the death certificate on a patint not going to autopsy



No doc is allowed to sign off on that anymore unless there is a VERY lengthy medical history.  The kid is going to get autopsied and there is going to be a police investigation.  The case has to be reported to the coroner/ME as well as child protective services by law in every state.  That death certificate isn't getting issued until the coroner OKs it.  In fact, in most states,_ every_ death gets reported to the coroner/ME and the only time the death certificate is signed by the doc is if the coroner/ME declines the case.  



> save a family that made a terrible mistake because they didn't know any better from criminal prosecution.



Ignorance of the law or failure to know something that the prudent layperson would know is not a valid defense.  My tolerance for "mistakes" is pretty low once said "mistake" starts claiming the lives of children.


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## MedicPatriot (Dec 18, 2011)

Veneficus said:


> Or until the doc signs it on the death certificate on a patient not going to autopsy in order to save a family that made a terrible mistake because they didn't know any better from criminal prosecution.



The other guy that commented is right though, its negligence. The really messed up part is that so many parents have no idea. I guess its mostly the uneducated.


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## usafmedic45 (Dec 18, 2011)

> Well our protocols actually have a "SIDS" category in which this patient falls into so that's how I worded it.



Seeing as how Maryland's protocols have not seen a serious revision in this century, it doesn't surprise me that you guys are still using terminology from the 1980s and 1990s before people started realizing that most "SIDS" cases were either missed homicides or deaths due to negligence.


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## MedicPatriot (Dec 18, 2011)

usafmedic45 said:


> Seeing as how Maryland's protocols have not seen a serious revision in this century, it doesn't surprise me that you guys are still using terminology from the 1980s and 1990s before people started realizing that most "SIDS" cases were either missed homicides or deaths due to negligence.



Thank you! We just got Dexamethasone in our protocols this year. We're catching up to that standard of care thing little by little. 

It isn't too bad in MD really. I just wish we had RSI.


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## usafmedic45 (Dec 18, 2011)

> Thank you! We just got Dexamethasone in our protocols this year. We're catching up to that standard of care thing little by little.



No, you're not.  The standard of care is so far ahead that as they throw one new thing at you every couple of years, fifteen other things that are still standards of care are even further behind.  



> It isn't too bad in MD really.



Yeah it is. I used to work there.  The sad state of EMS in Maryland is the _sole_ reason why I left there after I got out of the military.   That said, I guess I owe those crotchety archaic :censored::censored::censored::censored::censored::censored::censored:s at MIEMSS a certain degree of thanks because otherwise I would not have the great girl who is reading this over my shoulder.  My gratitude will be expressed by keeping the dancing and :censored::censored::censored::censored:ting on the grave of Robert Bass to a minimum once he dies.


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## MedicPatriot (Dec 18, 2011)

usafmedic45 said:


> No, you're not.  The standard of care is so far ahead that as they throw one new thing at you every couple of years, fifteen other things that are still standards of care are even further behind.
> 
> 
> 
> Yeah it is. I used to work there.  The sad state of EMS in Maryland is the _sole_ reason why I left there after I got out of the military.   That said, I guess I owe those crotchety archaic :censored::censored::censored::censored::censored::censored::censored:s at MIEMSS a certain degree of thanks because otherwise I would not have the great girl who is reading this over my shoulder.  My gratitude will be expressed by keeping the dancing and :censored::censored::censored::censored:ting on the grave of Robert Bass to a minimum once he dies.



I was being sarcastic about the standard of care thing.


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## EMTBHillbilly (Dec 18, 2011)

HA!  You guys should try EMS in WV.


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## STXmedic (Dec 18, 2011)

I don't think I want to try ANYTHING in WV.......


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