# Killing Your Patients



## Lifeguards For Life (Jun 22, 2011)

I remember when I was in school, how the instructors would tell us how our patient's life lies in our hands, and if we mess up we could easily kill someone.

I heard this in EMT school, but the message was a lot more common in Paramedic school.

I haven't thought too hard on this, but what honest, understandable mistakes can you imagine an EMT or PM making, that could kill a patient.

To be considered an understandable mistake, ask yourself "If I heard about this mistake being made, would I sympathize with the offending EMT/PM, or would I be horrified and think they were horribly incompetent ?"

For example, when I have asked this question before, the Medic instructor told me about a guy in his department who accidentally gave an elderly patient epi instead of morphine. He seemed to think this was an understandable mistake as these were the only two medications they caried that came in ampules. As all departments I am familiar with keep their narcs in a separate locked "narc box", and medications should be verified before being given, I have a hard time viewing this as an understandable mistake.

So, let's hear it. what mistakes can you imagine an EMS provider making in good faith, that could prove fatal to a patient.


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## SeanEddy (Jun 22, 2011)

I'm starting off with an easy one.....

Intubating the esophagus (without recognition). Although with Sp02, Capnography, and listening to the freaking lung sounds, it would be pretty hard NOT to recognize that.


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## HotelCo (Jun 22, 2011)

Lifeguards For Life said:


> I remember when I was in school, how the instructors would tell us how our patient's life lies in our hands, and if we mess up we could easily kill someone.
> 
> I heard this in EMT school, but the message was a lot more common in Paramedic school.
> 
> ...




Southeastern Michigan has only one drug box, with all meds inside of it. There is no separate narc box.


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## SeanEddy (Jun 22, 2011)

Forgetting to put the defibrillator in "sync" mode.


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## Lifeguards For Life (Jun 22, 2011)

SeanEddy said:


> I'm starting off with an easy one.....
> 
> Intubating the esophagus (without recognition). Although with Sp02, Capnography, and listening to the freaking lung sounds, it would be pretty hard NOT to recognize that.



I have seen this done twice, both times, it was obvious from across the room. Like you said there are so many simplistic tools to avoid this, that I think this is more neglect than a mistake.


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## LucidResq (Jun 22, 2011)

Driving recklessly.


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## Shishkabob (Jun 22, 2011)

Every time I give a medication. 



Every. Single. Time.


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## usalsfyre (Jun 22, 2011)

In good faith? Giving the wrong med due to poor labeling and extended shifts. Choosing the wrong sequence when controlling an airway (the sedative, succs, CPR sequence). Failure to recognize tension pneumothorax. Forgetting to hit synch. Failure to recognize shock. 

I've seen or done/come close to or know people who have seen or done all of these, some more "in good faith" than others.


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## abckidsmom (Jun 22, 2011)

Overall laziness that reduces your unit hour utilization to the point that you're not available for calls.

A system I know has extreme staffing issues, to the point that medics that are barely competent are cleared for duty and on a 1-paramedic unit.  In that system, it's seen as acceptable to spend an hour at the hospital.  If they could take hold of those lost hours, they would need a third fewer medic units all the time.

The dispatchers don't watch the system, and very commonly "cross trucks" who are responding to calls...having responding ambulances basically cross paths, when the calls should have been switched out.

Poor unit hour utilization leads to wasted money, and though this system seems to have a bottomless pit of money, it won't last forever.

(Can you tell I worked for AMR at one point, lol?  I really do believe that higher efficiency can be had if you ask for it and reward the crews for it.)

Wasted time and money in the system kills people, eventually.  It certainly has in the system I'm currently working in.


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## Lifeguards For Life (Jun 22, 2011)

SeanEddy said:


> Forgetting to put the defibrillator in "sync" mode.



Point.


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## Lifeguards For Life (Jun 22, 2011)

LucidResq said:


> Driving recklessly.



While this is not to be accepted, as you have labeled this behavior as reckless, and as such, is not a mistake.


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## Lifeguards For Life (Jun 22, 2011)

Linuss said:


> Every time I give a medication.
> 
> 
> 
> Every. Single. Time.



I don't buy into this one. "Every. Single. Time"?

Most of our meds have reversal agents, or are fairly benign in nature. And for the meds that do not fall under the afore mentioned categories, there is usually measures that can be taken to sustain life in the event of an overdose.

I fail to see how your patient is placed at any appreciable risk Every. Single. Time. you administer a med.


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## silver (Jun 22, 2011)

Lifeguards For Life said:


> Point.



Hey! I told you this a couple of days ago.

I think anything is possible really. People often have lapses of attention or get distracted and could easily incorrectly give a med (wrong dose/med/route etc.) or not notice indications/contraindications for a procedure.


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## abckidsmom (Jun 22, 2011)

Lifeguards For Life said:


> While this is not to be accepted, as you have labeled this behavior as reckless, and as such, is not a mistake.




Tell that to the guy who "accidentally" plowed into a family when he ran a red light.  Biggest mistake of his life.


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## EMSrush (Jun 22, 2011)

How about palpating a carotid BP using a manual cuff?


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## Lifeguards For Life (Jun 22, 2011)

silver said:


> Hey! I told you this a couple of days ago.
> 
> I think anything is possible really. People often have lapses of attention or get distracted and could easily incorrectly give a med (wrong dose/med/route etc.) or not notice indications/contraindications for a procedure.



Lol, i remember that chat room conversation. 

I had started to reply about unsynchronized cardioversion in hemodynamicaly unstable patients with VT, but this is worth a point. 

(I thought about it for a while, trying to argue, as I think that no matter what you do to your patients, most of them are going to live, but to argue this one would be stupid)


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## Lifeguards For Life (Jun 22, 2011)

abckidsmom said:


> Tell that to the guy who "accidentally" plowed into a family when he ran a red light.  Biggest mistake of his life.



don't run red lights?

EMS should not be driving recklessly plain and simple. 

I think there have been many threads here regarding the efficacy of running code 3, and most people would agree that in the majority of cases, L&S make a negligible contribution to patient care.

There is no reason for EMS to be running red lights.


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## abckidsmom (Jun 22, 2011)

Lifeguards For Life said:


> don't run red lights?
> 
> EMS should not be driving recklessly plain and simple.
> 
> ...



Well, yeah.  I totally agree with you.  But people do stupid stuff all the time, and you have to chalk it up to something.

I think that being lazy in the performance of your job can be equivalent to being reckless.  Is the monitor totally checked out?  Do we have the right masks to all of the ambu bags?  Etc.  Skipping that stuff can be the same level of recklessness that blowing a red light can be.

And sometimes you really just don't see the light.  That's when it is a mistake, be it one of distractedness, not looking, whatever, but I will give people credit for it being a mistake.

That doesn't exempt them from the consequences of the mistake.


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## sir.shocksalot (Jun 22, 2011)

Lifeguards For Life said:


> There is no reason for EMS to be running red lights.


As much as I agree that time is hardly a factor in most disease processes that we encounter, I don't think the public would stand for 20 to 30 minute response times.

However, of the response time studies I have read they made no mention of the environment that is being responded in. When I worked in some rural and suburban parts of CO going L/S made zero to negligible time difference. In a large, dense, urban area L/S can turn a 20 minute response down to 8 minutes.

But I will maintain that safety and caution should always be the #1 priority regardless of distance that you are responding from or what you are responding to. Don't end up on the 6 am news.


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## MrBrown (Jun 22, 2011)

The only thing that could be fatal as Brown sees it is bad driving, but there are lots of things that are not always good for your patients .... like high flow oxygen, glucose in stroke, frusemide for CHF, suxamethonium in hyperkalemia, IV fluids in people with CHF etc etc etc 

Oh, there is one really bad, almost certainly always fatal thing ... letting Brown work on you


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## SeanEddy (Jun 22, 2011)

sir.shocksalot said:


> As much as I agree that time is hardly a factor in most disease processes that we encounter, I don't think the public would stand for 20 to 30 minute response times.



They seem to tolerate twice, if not 3 times the wait time for an ER visit. It's our own fault that we built this system around response times and advertised it as such. I would venture out to say at least 80% of our responses don't benefit from a code-3 response. 

Only in EMS will you get seen RIGHT NOW regardless of your complaint.


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## Lifeguards For Life (Jun 22, 2011)

SeanEddy said:


> They seem to tolerate twice, if not 3 times the wait time for an ER visit. It's our own fault that we built this system around response times and advertised it as such. I would venture out to say at least 80% of our responses don't benefit from a code-3 response.
> 
> Only in EMS will you get seen RIGHT NOW regardless of your complaint.



how many of you guy's walk to the rescue/ambulance, or run to the restroom real quick before getting in the rescue?

Do you ever run on scene?

L&S don't save a lot of time in most cases, and in the times when they do save any amount of time, we are maneuvering around still traffic extremely slowly, with the air horns blazing.

I think there is some sort of study/article floating around claiming that the majority of EMS patients are better off being transported in their POV.


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## sir.shocksalot (Jun 22, 2011)

Lifeguards For Life said:


> Do you ever run on scene?


Every time. I also kick down the door on every EMS call. Adds dramatic effect and lets the patient know that I am a badass motherf*cker.


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## usalsfyre (Jun 22, 2011)

sir.shocksalot said:


> Every time. I also kick down the door on every EMS call. Adds dramatic effect and lets the patient know that I am a badass motherf*cker.


Running in slow-mo doesn't count though...


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## DrParasite (Jun 22, 2011)

MrBrown said:


> frusemide for CHF


point of information: isn't furosemide/Lasix a standard treatment for CHF?  



Lifeguards For Life said:


> how many of you guy's walk to the rescue/ambulance, or run to the restroom real quick before getting in the rescue?


Sad/scary part is, I know of systems that will talk a stable and ambulatory patient to the ambulance, and then transport lights and sirens to the hospital, where the person is put into a wheelchair and left in triage.

and the even scarier part is, the justification for doing this is that there are job pending, and they are too busy to transport non-emergency for non-life threats.


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## Smash (Jun 22, 2011)

DrParasite said:


> point of information: isn't furosemide/Lasix a standard treatment for CHF?



I will assume on Browns behalf that he means acute cardiogenic pulmonary edema as opposed to the long term medical management of congestive heart failure.


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## Smash (Jun 22, 2011)

usalsfyre said:


> Running in slow-mo doesn't count though...



That's the only way I ever run. Not that I mean to, it just works out that way...


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## rhan101277 (Jun 22, 2011)

Administering .3-.5mg 1:1000 epi IVP for suspected anaphylaxis, even though patient has no respiratory component, just hives.


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## SeanEddy (Jun 22, 2011)

rhan101277 said:


> Administering .3-.5mg 1:1000 epi IVP for suspected anaphylaxis, even though patient has no respiratory component, just hives.



That's not really a good-faith mistake. That's a result of a poor assessment.


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## SeanEddy (Jun 22, 2011)

Lifeguards For Life said:


> I think there is some sort of study/article floating around claiming that the majority of EMS patients are better off being transported in their POV.



Yea it's called 95% of the calls I run not even needing an ambulance, much less a code-3 response. It's pretty ridiculous.


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## CAOX3 (Jun 23, 2011)

DrParasite said:


> point of information: isn't furosemide/Lasix a standard treatment for CHF?.



In somee places Im sure it is, not here.

Volume depletion.

At times it can be difficult to differentiate pneumonia, exacerbation COPD and CHF


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## MrBrown (Jun 23, 2011)

rhan101277 said:


> Administering .3-.5mg 1:1000 epi IVP for suspected anaphylaxis, even though patient has no respiratory component, just hives.



Um yeah, that dose of such concentrated adrenaline is likely to have a bit of an effect all right 

... and yes, that's like super assessment fail, but not as bad as those Los Angeles City Fire Paramedics who gave frusemide to a lady with leg pain because it had to be CHF .... (yes, thats in the literature somewhere, Brown has read it)


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## Death_By_Sexy (Jun 23, 2011)

Wasting time and trying to be the hero onscene during a trauma call, in lieu of extremely rapid transport.


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## MrBrown (Jun 23, 2011)

Death_By_Sexy said:


> Wasting time and trying to be the hero onscene during a trauma call, in lieu of extremely rapid transport.



Please elaborate because this is a potential super-mega-hella-king sized-value meal-US EMS fail right here.


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## Foxbat (Jun 23, 2011)

MrBrown said:


> Please elaborate because this is a potential super-mega-hella-king sized-value meal-US EMS fail right here.



What's interesting is that I heard Russian EMS providers (physicians and physician assistants mostly) often criticizing US EMS precisely for "load and go" approach for life-threatening conditions, including major trauma. They basically say "paramedics over there are trying to transport unstable patients rather than stabilize them on scene, so their patients end up dying en route or shortly after arrival".


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## mycrofft (Jun 23, 2011)

*Know when to boogie and where to.*

Until ambulances have operating rooms, labs, and diagnostics beyond basically EKG, stethoscope, BP cuff and a couple others (yes, I simplify, but not too much), there are cases where if you get bogged down trying to resuscitate when the trouble is out of your league, your delay will make demise more likely. Like, any STAT belly, obstetric emergencies, intracranial bleeds, dissecting aortas...the list goes on and on.

On a simpler note, how about strapping on the oxygen mask then something occludes the line or the oxygen runs out and you fail to notice? "Non-rebreather" gains a whole new depth of meaning there.


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## DrParasite (Jun 23, 2011)

Foxbat said:


> What's interesting is that I heard Russian EMS providers (physicians and physician assistants mostly) often criticizing US EMS precisely for "load and go" approach for life-threatening conditions, including major trauma. They basically say "paramedics over there are trying to transport unstable patients rather than stabilize them on scene, so their patients end up dying en route or shortly after arrival".


You are comparing apples to pears....  

a physicians and a physician assistant can do more than a paramedic.  can a paramedic insert a chest tube?  can a physician?

the load and go approach is used because in the majority of multi system traumas, the patient needs a trauma center, for both the assessment tools and the trauma surgeons to fix the problems.  

there is only so much you can do in the ambulance.  a hospital ER has more staff, more interventions, and more diagnostic tools than a paramedic does in the back an ambulance.

truly sick people need an ER (and all the support that comes with it), not a paramedic.  the latter can only do so much in a short amount of time, the former is better suited to both treat and long term manage the patient


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## MrBrown (Jun 23, 2011)

Brown wonders how much of "load and go" is underassessment and overtriage.


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## Akulahawk (Jun 23, 2011)

DrParasite said:


> You are comparing apples to pears....
> 
> a physicians and a physician assistant can do more than a paramedic.  can a paramedic insert a chest tube?  can a physician?
> 
> ...


While a Physician and a PA will undoubtedly have more education than a Paramedic will... Trauma victims need a surgeon, an OR and enough hands to make sure that everything is ready to support the patient. Last time I checked, an ambulance makes for a poor OR and generally lack enough trained hands to do the job well (let alone have sufficient supplies of, well, everything because you'd have to be ready for any surgical need...)

Truly sick people do need an ER. Why? All the support/resources available. An ambulance doesn't (yet) have the ability to do portable X-ray and doesn't have a CT scanner. While there is bedside lab equipment out and about in the world, a much better lab capability is available to the ER. There are Pharmacy services available there too. An ambulance can stock only so much. 

"Stay and play" vs "load and go" is a very old argument that _does_ need to be rehashed every so often to make sure that those patients that should be stabilized on scene, are while the patients that need transport urgently should get it... regardless of who is staffing the ambulance. 

Delete the Paramedic vs MD/PA stuff and a good argument was made by DrParasite about the limitations of ambulances.


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## the_negro_puppy (Jun 23, 2011)

Smash said:


> I will assume on Browns behalf that he means acute cardiogenic pulmonary edema as opposed to the long term medical management of congestive heart failure.



I am confused. I have seen lasix/frusemide used to treat cardiogenic APO and as a prescribed diuretic in CCF/CHF patients.


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## Akulahawk (Jun 23, 2011)

MrBrown said:


> Brown wonders how much of "load and go" is underassessment and overtriage.


I might lean more towards overtriage than underassessment. Some might have to do with knowing that there's only so much that can be done in the field with the limited resources available. 

Put a Doc on a BLS ambulance and tell that Doc that those supplies are all you have to work with... You're still going to have a number of transports of relatively non-emergent patients simply because the Doc needs more info or the patient needs stuff done that can't be done right there. You'd also see a much larger number of exam and referrals to appropriate resources than is done now. 

Personally, I think that overtriage is a BIG EXPENSIVE PROBLEM in the current design of trauma systems today. Clearly it's done so that "something" isn't missed. Personally I think that transports to trauma centers based on mechanism alone happen too often. Injury NEVER happens without a mechanism to cause it. If you can determine the MOI, you then have a good idea where to look for signs of actual injury...


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## firetender (Jun 23, 2011)

*How we kill*

Let's get back to the original question...



			
				Lifeguards for life said:
			
		

> the instructors would tell us how our patient's life lies in our hands, and if we mess up we could easily kill someone.
> 
> I heard this in EMT school, but the message was a lot more common in Paramedic school.
> 
> So, let's hear it. what mistakes can you imagine an EMS provider making in good faith, that could prove fatal to a patient.


 

You can make a list and check it twice and try to figure who's naughty and nice and it will get you no closer to avoiding killing someone in the field..

The fact is, the nature of the job is that its practitioners place themselves in innumerable positions to be an agent of the death of other human beings.

Fortunately, in my experience, it generally takes a lot to kill someone in the back of an ambulance. It's usually a combination of factors, only one or two of which were contributed by you. There's what you found at the scene which includes a history behind it all that you can't possibly see, and the future response of the person to what you administer which, when it goes sour, you typically can't predict, and even if you catch your mistake, it's too late.

So, sometimes, you're stuck with a present moment where it really looks like you killed the unlucky patient.  

This is how, sometimes, the twisted gods conspire to bring a whole lot of contributing factors together that, alone would not do anything serious, but when you show up you just happen to offer the pressure that collapses the house of cards.

...and it could be anything. It could be any time. It would just happen to be the very wrongest thing at the worst time and you happen to be the poor schmuck that administered it.

So the thread asks, essentially, what is forgiveable and what is innocent? Everything, perhaps except a wilfull intention to harm or a commitment to neglect.

We place ourselves in the paths of others' fate and sometimes, we determine it. It's the nature of the beast.

(The above opinion is that of firetender and does not necessarily reflect the view of EMTLife.com or the views of its Community Leaders.)


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## MrBrown (Jun 23, 2011)

Akulahawk said:


> I might lean more towards overtriage than underassessment. Some might have to do with knowing that there's only so much that can be done in the field with the limited resources available.
> ...



True, but Brown was referring specifically to the mentality of "drag everybody out, throw them in the ambulance and race them to the hospital" mentality which seems to exist in the US because that is what your poorly written, outdated textbook tells you.


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## DrParasite (Jun 23, 2011)

MrBrown said:


> True, but Brown was referring specifically to the mentality of "drag everybody out, throw them in the ambulance and race them to the hospital" mentality which seems to exist in the US because that is what your poorly written, outdated textbook tells you.


Amazing.  Brown is not only an expert on EMS and medicine, but he is an expert on the mentality of American EMS, as well as what is written in the the American EMS textbooks.  this is amazing because he has never attended an EMS course in the US, and I'm betting he has never stepped foot on a US ambulance nor worked in an Urban or rural American EMS system.  

but Brown is an expert in how we do everything wrong.  Amazing how that works out.


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## the_negro_puppy (Jun 23, 2011)

DrParasite said:


> Amazing.  Brown is not only an expert on EMS and medicine, but he is an expert on the mentality of American EMS, as well as what is written in the the American EMS textbooks.  this is amazing because he has never attended an EMS course in the US, and I'm betting he has never stepped foot on a US ambulance nor worked in an Urban or rural American EMS system.
> 
> but Brown is an expert in how we do everything wrong.  Amazing how that works out.



Brown is probably basing his opinion on the criticism Brown reads about US EMS that other US EMS folk post on here.  How now Brown cow.


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## CAOX3 (Jun 23, 2011)

MrBrown said:


> True, but Brown was referring specifically to the mentality of "drag everybody out, throw them in the ambulance and race them to the hospital" mentality which seems to exist in the US because that is what your poorly written, outdated textbook tells you.



Actually it probably has more to do with the fear of litigation then anything else.

Somewhere along the way everyone became paranoid about being sued.  

Everyone s looking over their shoulder for the  boogyman, to a point where it effects patient care.  They do it even if it isn't in the best interest of the patient to cover their butt.


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## johnrsemt (Jun 23, 2011)

EMT-B spiking a 500mL bag of Lidocaine instead of NS;  and medic giving pt 400mL bolus before it was caught at ED:  Basic and Medic both made mistake.
Basic for not making sure he grabbed right bag, medic for not checking it before administering it.
   Giving entire 1mg Epi 1:1,000 for allergic reaction because "if they really wanted us to only give 0.15mg to a 3 y/o it would come that way"  RN at ED.
   Atropine instead of Adenocard,   misread.
   Adenocard given through 22 g in hand, with no push.  "made no sense to push a fast flush afterward, so I didn't"  Medic mill training schools, not enough time for them to truly learn what they were doing.
   D-50 into an infiltrated AC IV on an unconscious patient.  couldn't figure out why it was so hard to push D-50 through a 18 g IV.
   Field Subclavian line in cardiac arrest:  wasn't in vein;  gave 2 liters of fluid, and 40 minutes of ACLS drugs, into a very large pneumothorax.
   Ketorlac given instead of Ketamine.

lots of 'mistakes' can hurt or kill a patient or make their life miserable.


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## Shishkabob (Jun 23, 2011)

Lifeguards For Life said:


> Most of our meds have reversal agents, or are fairly benign in nature.
> 
> I fail to see how your patient is placed at any appreciable risk Every. Single. Time. you administer a med.




Lidocaine.  Benign?
Amiodarone.  Benign?
Nitroglycerine.  Benign?
Etomidate.  Benign?
Roc.  Benign?
Mag sulfate.  Benign?
Atropine.  Benign?
Levophed.  Benign?
Dopamine.  Benign?


That's just a small portion of the medications I carry on my truck, medications I can give any time I please without any sort of oversight.

On top of that, I carry a single (true) reversal agent on my truck, Narcan, and that itself isn't to be considered benign due to the severe consequences that can happen from it's administration.




Most of the medications we carry are poisons to the body, just generally used in a particular manner to hopefully limit bad outcomes.


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## jonesy0924 (Jun 23, 2011)

the majority of mistakes are preventable. You should read the label and confirm it before giving it...make sure your truck is equiped right...just double checking will prevent a mistake...all medics will have patients die while on the job but none should be killed by them


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## usalsfyre (Jun 23, 2011)

jonesy0924 said:


> the majority of mistakes are preventable. You should read the label and confirm it before giving it...make sure your truck is equiped right...just double checking will prevent a mistake...all medics will have patients die while on the job but none should be killed by them



The issue is EMS tends to completely discount engineering controls and discount them. An example is the morphine and epi in similar looking ampules. Yes, it should be double checked. Often times it's not, and refusal to acknowledge this fact is living in a fantasy land. 

All of this is compounded by extended shifts. One place I worked even forbid napping during the day, even though the truck I was on commonly ran 20+ calls in a 24hr period. When it was pointed out that this was perhaps suboptimal, it was implied we were lesser men and unable to "work hard without whining".

EMS would benefit greatly from well applied engineering controls. I fear the "aluminum trucks and iron paramedics" mentality will continue for a long time.


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## jonesy0924 (Jun 23, 2011)

in total agreement with what was  just said. most are over worked...I too worked for an agency that had meds that were packaged very alike. That is when knowing your equipment and truck comes into play. In my case it was the versed and a think benadryl they were in almost the same packaging...we just moved one to a different area. We also had times when we had two different vials witht he same med just packaged different..example we had 10mg in 10ml and another that was 10mg in 1 ml..this is do to buying fron the lowest bidder most of the time..in my opinion knowing what you have and where it is is very important...rest is another big factor....you shhould be allowed to sleep but with restrictions like after 5 pm or during a certain time...we always set a luch time didnt mean we got it but we could nap during that time.....


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## Lifeguards For Life (Jun 23, 2011)

Linuss said:


> Lidocaine.  Benign?
> *Lidocaine toxicity is treatable*
> 
> Amiodarone.  Benign?
> ...



Yes, "mistakes" are possible, but unlikely to be lethal.


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## Lifeguards For Life (Jun 23, 2011)

rhan101277 said:


> Administering .3-.5mg 1:1000 epi IVP for suspected anaphylaxis, even though patient has no respiratory component, just hives.



In our systems epi 1:1 comes packaged in an amp and 1:10 comes packaged in that preloaded plunger thing, so to mix them up would be difficult (granted I know this may not be the case in all systems, though it seems to be fairly common).


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## jonesy0924 (Jun 23, 2011)

epi was the same one in amps other in a box for us too


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## usalsfyre (Jun 23, 2011)

jonesy0924 said:


> you shhould be allowed to sleep but with restrictions like after 5 pm or during a certain time...we always set a luch time didnt mean we got it but we could nap during that time.....


The only thing I disagree with is this. If all other task are complete, I'm probably looking for a flat surface. Because it doesn't matter if I'm asleep at 10:00 in the morning or midnight. The rest and subsequent improvement in decision making is the same.


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## jonesy0924 (Jun 23, 2011)

at the time i was working for a fire agency and until 5 you were up...sometimes before that you might get a nap..they had us training and preplanningn and what not...I just got hired with an ems only agency and dont know what there policy is yet ....i agree with you though about sleeping...I was usually the first one to hit the rack when i was working...


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## Epi-do (Jun 23, 2011)

usalsfyre said:


> Running in slow-mo doesn't count though...



But it looks good on the evening news.


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## BEorP (Jun 23, 2011)

Lifeguards For Life said:


> Nitroglycerine. Benign?
> yes.



How is nitro benign?

You can definitely do some damage, particularly if someone is having a RV infarction.


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## jonesy0924 (Jun 23, 2011)

or if they have no pressure to begin with


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## Zodiac (Jun 23, 2011)

I witnessed some ER nurses knock a patient's BP down from 130/Something to 30/15 because they apparently applied nitro paste and forgot about it. She was darn near circulatory collapse by the time anybody thought to check on her. Talk about close calls. :glare:


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## Lifeguards For Life (Jun 23, 2011)

BEorP said:


> How is nitro benign?
> 
> You can definitely do some damage, particularly if someone is having a RV infarction.



Run it as a drip. Hlaf life is about 8 seconds. If the BP starts to fall simply shut off the drip.

While you could knock a bp down with  SL or topical nitro, the patient could just as easily do the same with their own nitro.

If the Pt is having an MI with RV involvement, or even taken any phosphodiesterase inhibitors, they are just as likely, possibly even more so, to give themselves nitro, than emergency personnel is.


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## Lifeguards For Life (Jun 23, 2011)

BEorP said:


> You can definitely do some damage, particularly if someone is having a RV infarction.



Even with RV involvement, Nitro is just a relative contraindication.


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## Lifeguards For Life (Jun 23, 2011)

Zodiac said:


> I witnessed some ER nurses knock a patient's BP down from 130/Something to 30/15 because they apparently applied nitro paste and forgot about it. She was darn near circulatory collapse by the time anybody thought to check on her. Talk about close calls. :glare:



But this was not a fatal mistake?


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## usalsfyre (Jun 23, 2011)

Lifeguards For Life said:


> Even with RV involvement, Nitro is just a relative contraindication.



Except the American College of Cardiology says it's a class III intervention for RVI...


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## Lifeguards For Life (Jun 23, 2011)

usalsfyre said:


> Except the American College of Cardiology says it's a class III intervention for RVI...



Class III interventions mean no proven benefit or potentially harmful right?

I wouldn't give a pt with an RVI Nitro SL, but do you think doing so is a death sentence?

I would give them nitro as a drip though


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## usalsfyre (Jun 23, 2011)

Lifeguards For Life said:


> Class III interventions mean no proven benefit or potentially harmful right?
> 
> I wouldn't give a pt with an RVI Nitro SL, but do you think doing so is a death sentence?
> 
> I would give them nitro as a drip though



Yep, class III is bad.

Not a death sentence, but not helpful.

Considering NTGs benefit in AMI is dubious anyway, I'm probably going to withhold it for RVI period and control the pain with hemodynamiclly stable opiates.


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## Lifeguards For Life (Jun 23, 2011)

usalsfyre said:


> Yep, class III is bad.
> 
> Not a death sentence, but not helpful.
> 
> Considering NTGs benefit in AMI is dubious anyway, I'm probably going to withhold it for RVI period and control the pain with hemodynamiclly stable opiates.



It's not really that I disagree with you, I just want to explore the idea that it is not as easy to make a mistake and kill a patient as some medics would have you believe.


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## usalsfyre (Jun 23, 2011)

Lifeguards For Life said:


> It's not really that I disagree with you, I just want to explore the idea that it is not as easy to make a mistake and kill a patient as some medics would have you believe.



NTG infusions, for all the fear surrounding them, are MASSIVELY safer than SL NTG. It is indeed hard to kill someone with NTG. Although not an RVI obviously, I have been known to give a 1.2 MILLIGRAM loading dose SL and run an infusion of NTG between 50 and 100mcg/min for severe CHF. Never seen an ill effect and patients get better. The ED nurses freak out with a 100mcg infusion though.


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## mycrofft (Jun 24, 2011)

*Many people in medicine say the tech caused the death when it was due to the insult.*

In the course of impressing upon their students how important it is not to make mistakes (and by extension how important it is for them to listen to and believe the teacher uncritically), they take the opportunity to bully and haze them with this. Typical quasi basic training boot camp frickafrack.

Mostly, you can screw up and the original insult still kills; the insult was inevitably and promptly lethal and they die with you even if you do it right; you take too long or act timidly, and etc etc as above. Sometimes you treat too aggressively, then your measure kills the pt or hurries the insult's effect. Sometimes it is the wrong treatment and it exacerbates the insult or preextant condition, and you kill them. Or you do something that *in and of itself* is lethal such as the oxygen mask/smothering I described earlier. Most times, the tech didn't do it, but failed to prevent it.


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## BEorP (Jun 24, 2011)

Lifeguards For Life said:


> Run it as a drip. Hlaf life is about 8 seconds. If the BP starts to fall simply shut off the drip.
> 
> While you could knock a bp down with  SL or topical nitro, the patient could just as easily do the same with their own nitro.
> 
> If the Pt is having an MI with RV involvement, or even taken any phosphodiesterase inhibitors, they are just as likely, possibly even more so, to give themselves nitro, than emergency personnel is.



I really don't understand what you are trying to prove here. 

Nitro is commonly administered SL and is not benign. Just because a patient could do it to themselves or you can propose a safer way does not change the fact that the drug, as commonly administered, can be dangerous.


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## Lifeguards For Life (Jun 24, 2011)

BEorP said:


> I really don't understand what you are trying to prove here.



That Linuss does not run the risk of making a fatal mistake Every. Single. 
Time. he gives a patient a medication


And yes, while it can be harmful, do you really feel as if a provider is likely to accidentally kill a patient with it?


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## Zodiac (Jun 24, 2011)

Lifeguards For Life said:


> And yes, while it can be harmful, do you really feel as if a provider is likely to accidentally kill a patient with it?



With the right level of incompetence, anything is deadly.


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## BEorP (Jun 24, 2011)

Lifeguards For Life said:


> That Linuss does not run the risk of making a fatal mistake Every. Single.
> Time. he gives a patient a medication
> 
> 
> And yes, while it can be harmful, do you really feel as if a provider is likely to accidentally kill a patient with it?



I'm not trying to get in between you and Linuss.

In the initial post, you asked: "So, let's hear it. what mistakes can you imagine an EMS provider making in good faith, that could prove fatal to a patient."

Giving nitro to an RVI could do that. I think we're on the same page on that.

Now, could an EMS provider do it by accident? Absolutely. Many paramedics in at least one region routinely give nitro without a 12 lead. And even when a 12 lead is available, it is possible to miss something on it. 

Will everyone give SL nitro to an RVI? No.
Will it always kill them if they do? No. 
Is this something that I am claiming frequently happens? No.

But it is most definitely a way an EMS provider could accidentally kill a patient.


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## mycrofft (Jun 24, 2011)

*Maybe nitro needs a separate thread?*

If I was treating an unconscious man in a Las Vegas hotel I'd be very chary about whipping on the nitro, due to the Viagra situation there...h34r:


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## firetender (Jun 24, 2011)

This is going in the same direction as medicine: fixating on the individual modality in an attempt to treat what is essentially a set of symptoms rather than stepping back and seeing the patient as a whole entity.

A call involves treating a past and present with many, many variables. In the absence of willfully administering a therapy that is known to exacerbate a bad situation, what we do to kill a patient is usually contributory, not decisive.


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## Tigger (Jun 24, 2011)

I'm having a hard time trying to figure out what a forgivable mistake is, or one that is made in good faith. Everything that I think of always seems to also be equatable to negligence, and I have to wonder how forgivable negligence is.

The one "mistake" that I can come up with is with the stretcher. You're transporting a patient to the ambulance across a parking lot. Neither you nor your partner see a hole in the pavement ahead. One stretcher wheel get's jammed up, the stretcher tips, and the patient strikes his head and dies. 

Admittedly, this a far fetched scenario. But can, and has happened in Newport News and in the Boston area. Not sure what the rules are about posting links to news stories.


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## silver (Jun 24, 2011)

Healthcare associated infections (HAIs) are something that can kill patients as well. Something like MRSA or even a "garden variety" infection could be picked up from skin contact, IV placement, central lines etc. and result in a nasty infection and sepsis.

Even with the best EMTs/Medics some infections can't be prevented.


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## usalsfyre (Jun 24, 2011)

Tigger, not to pick on you, but that attitude does nothing but encourage hiding mistakes. 

EMS needs to learn from the medical model of training.


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## Tigger (Jun 24, 2011)

I guess I was looking at things more from a legal perspective, in that regardless of intent, negligence is negligence. That said, that's not how I personally look at mistakes. I absolutely understand that a paramedic could err in drawing up a medication and kill a patient. I understand we are all humans and mistakes will happen. Hopefully such an incident would be correctly managed and would not have to end in the paramedics immediate termination.

I know that differentiating from BLS and ALS is not something that EMS needs, but I guess from the basic prospective, there's not a whole lot I can do to even hasten a patient's death, much less kill the patient.


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## firetender (Jun 25, 2011)

Tigger said:


> II guess from the basic prospective, there's not a whole lot I can do to even hasten a patient's death, much less kill the patient.


 
You're young. You'll learn.


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## Lifeguards For Life (Jun 25, 2011)

Tigger said:


> I guess from the basic prospective, there's not a whole lot I can do to even hasten a patient's death, much less kill the patient.



There is however, a lot you can do to help a patient


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## mycrofft (Jun 25, 2011)

*Mistake versus Accident, again.*

Mistake: try to make the ambulance litter straddle the hole in the sidewalk, but it goes in anyway; you did what you meant to do, but it was wrong. Intent was present.
Accident: you didn't see that hole in the pavement and fell into it. Lack of intent.
Neglect, malpractice, or being unprofessional: didn't look for the hole in the pavement, accident or not.

Medicine tries to be a zero-mistake field. It has become populated with people unwilling to grant the fact of human error because to deny it gives them the whip hand. It has also become the hunting preserve of non-medical administrators and lawyers using the same unassailable strategy. So, instead of sharing mistakes, owning up, learning from others as well as ourselves, we find ways to hide mistakes, distribute blame, or cover ourselves at the expense of others (and sometimes the expense of reason) to avoid this sort of weeding-out or punishment. Do the right thing in good faith each and every time.


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## firetender (Jun 25, 2011)

*Hit the nail on the head!*



mycrofft said:


> Medicine...a zero-mistake field...populated with people unwilling to grant the fact of human error... instead of sharing mistakes, owning up, learning from others as well as ourselves, we find ways to hide mistakes...distribute blame...cover ourselves at the expense of others...of reason... to avoid... punishment [/QUOTE]
> 
> In both subtle and not so subtle ways, punishment often appears to be for being a human in an extremely demanding field. Even speaking honestly amongst ourselves is covertly discouraged.
> 
> ...


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## Sandman-EMT (Jun 25, 2011)

SeanEddy said:


> Yea it's called 95% of the calls I run not even needing an ambulance, much less a code-3 response. It's pretty ridiculous.



That's exactly right Sir!


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## zzyzx (Jun 26, 2011)

Besides the many instances of med errors and esophageal intubations...

1) Blowing off ALOC as ETOH and not realizing the patient had in fact received a head injury from an assault.

2) "It's just acid reflux. Call us back if you feel worse."

3) Epi 1:1,000 IVP (not 1:10,000) for anaphylaxis.

4) Missing trauma patients, like little old lady found by the wrecking yard operator under the passenger side dash. (LA County)

These ones are well know to people on this site. Advice to the OP would be to read the EMS news posts and learn from other people's mistakes.

Other mistakes that I have witnessed or that I have heard of locally:

1) The medic who believed the cop when he said the guy involved in the minor T/C was drunk. He AMA'ed a surgeon who'd crashed his car after suffering from a hemorrhagic stroke.

2) Firefighter (though it could have been anyone) yelling at the hyperventilating patient, telling her to call down, and not recognizing the she was having a massive PE.

3) Medics who transported the "homeless guy" w/o providing treatment and not recognizing he was hypoglycemic.

There's lots more...just can't remember the other classic FAILS right now.


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## usalsfyre (Jun 26, 2011)

zzyzx said:


> 3) Epi 1:1,000 IVP (not 1:10,000) for anaphylaxis.



Hopefully you mean because the wrong dose was pushed h34r:


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## Smash (Jun 26, 2011)

usalsfyre said:


> hopefully you mean because the wrong dose was pushed h34r:



lol!


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## zzyzx (Jun 27, 2011)

I mean someone using undiluted epi IV push....

Another classic FAIL that was previously discussed on this site (or EMT City?) was the medic who didn't recognize agitation/combativeness as due to hypoxia and did nothing but administer Benadryl.

Or the medic who, or at least it was claimed, fell asleep in the back of the ambulance on an transfer, and woke up upon arrival at the hospital with the patient deceased.:unsure:


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## usalsfyre (Jun 27, 2011)

zzyzx said:


> I mean someone using undiluted epi IV push....


Good God do we gave to beat this horse again....

Assuming the same DOSE, there is no difference between 1:1000 and 1:10000 when given IV push.


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## Lifeguards For Life (Jun 27, 2011)

usalsfyre said:


> Good God do we gave to beat this horse again....
> 
> Assuming the same DOSE, there is no difference between 1:1000 and 1:10000 when given IV push.



We are habitual horse-beaters here.


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## zzyzx (Jun 27, 2011)

Yeah, I remember that thread as well. Sorry, I was referring to the incident where the crew slammed 1/2 mg undiluted IVP.


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## usalsfyre (Jun 27, 2011)

zzyzx said:


> Yeah, I remember that thread as well. Sorry, I was referring to the incident where the crew slammed 1/2 mg undiluted IVP.


Yeah, when you overdose the patient because your not paying attention to concentration....that's what management calls "an issue" .


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## CAOX3 (Jun 27, 2011)

Lifeguards For Life said:


> We are habitual horse-beaters here.



So much so I believe PETA is investigating.


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## Too Old To Work (Jul 7, 2011)

Lifeguards For Life said:


> I don't buy into this one. "Every. Single. Time"?
> 
> Most of our meds have reversal agents, or are fairly benign in nature. And for the meds that do not fall under the afore mentioned categories, there is usually measures that can be taken to sustain life in the event of an overdose.
> 
> I fail to see how your patient is placed at any appreciable risk Every. Single. Time. you administer a med.



Wow, that's a dangerous way to think. No doubt you will kill more than your fair share of patients. In fact, you should take to putting a cross on the fender of your ambulance for each confirmed kill, just like they did in WWII. That's if you even recognize what that you killed the patient. Yes. Every. Single. Time. There are some drugs that don't scare me much, but there are some drugs I give where I am terrified, Every. Single. Time. That's not because I don't know what they can do, but because I know exactly what they can do. Every. Single. Time. 



DrParasite said:


> Amazing.  Brown is not only an expert on EMS and medicine, but he is an expert on the mentality of American EMS, as well as what is written in the the American EMS textbooks.  this is amazing because he has never attended an EMS course in the US, and I'm betting he has never stepped foot on a US ambulance nor worked in an Urban or rural American EMS system.
> 
> but Brown is an expert in how we do everything wrong.  Amazing how that works out.



I wish I was half the medic that Brown fancies himself to be. Then I'd be a Hero Medic for the 21st century. If you don't know who hero medic was, then you missed out on a very rich part of pre Internet EMS forums. 



Akulahawk said:


> While a Physician and a PA will undoubtedly have more education than a Paramedic will... Trauma victims need a surgeon, an OR and enough hands to make sure that everything is ready to support the patient. Last time I checked, an ambulance makes for a poor OR and generally lack enough trained hands to do the job well (let alone have sufficient supplies of, well, everything because you'd have to be ready for any surgical need...)



Not to mention that an EMT or paramedic's knowledge is really only skin deep. Most doctors are smarter than most paramedics. Not all, but most of them. 



> Truly sick people do need an ER. Why? All the support/resources available. An ambulance doesn't (yet) have the ability to do portable X-ray and doesn't have a CT scanner. While there is bedside lab equipment out and about in the world, a much better lab capability is available to the ER. There are Pharmacy services available there too. An ambulance can stock only so much.



Yes. 



> "Stay and play" vs "load and go" is a very old argument that _does_ need to be rehashed every so often to make sure that those patients that should be stabilized on scene, are while the patients that need transport urgently should get it... regardless of who is staffing the ambulance.
> 
> Delete the Paramedic vs MD/PA stuff and a good argument was made by DrParasite about the limitations of ambulances.



Since we only temporize and only rarely do we make a patient completely "better" than it's axiomatic that transport is part of the treatment. 

As to having doctors on ambulances because they can "do more", how did that work out for Princess Diana? She had a slow bleeding tear in (I believe) the IVC that could have been surgically repaired fairly easily. If the MD staffed French ambulance hadn't stayed on scene trying to stabilize her, then she might have survived.


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## Lifeguards For Life (Jul 7, 2011)

I maintain that no matter what you do to them, most of your patients will  live.


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## Too Old To Work (Jul 7, 2011)

Lifeguards For Life said:


> I maintain that no matter what you do to them, most of your patients will  live.



While that might be true, I maintain that if that is your approach to EMS then we'd all be better off if you went into something more suited to your abilities. The fast food industry comes to mind.


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## firetender (Jul 7, 2011)

*Let's keep it civil*

Each of us comes to certain conclusions about who we are in relationship to the work we do.

Every one of us has the right to learn and better understand what we are in the midst of.

The purpose of this forum, to me, in part, is to allow our peers to come in, state their opinions of the moment, learn from the responses given them and then evolve their positions.

TOTW, you're judging an EMS provider on his ability to serve based on one statement that absolutely does NOT reflect who the provider is.

I happen to agree with him...sometimes. And sometimes as well there are runs where nothing you do can save a patient. EMS experience is fluid, not fixed, and I'd much prefer you help your peers see more aspects than their own rather than belting them for the only one they can see today.


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## Too Old To Work (Jul 7, 2011)

firetender said:


> TOTW, you're judging an EMS provider on his ability to serve based on one statement that absolutely does NOT reflect who the provider is.
> 
> I happen to agree with him...sometimes. And sometimes as well there are runs where nothing you do can save a patient. EMS experience is fluid, not fixed, and I'd much prefer you help your peers see more aspects than their own rather than belting them for the only one they can see today.



Actually, I'm basing it on several posts of his. This just happens to be one of the less well reasoned ones. You may agree with him, I don't. What we do is fraught with risk, more for the patient than for us. We have a drug box full of medications that can cause great good, or cause great harm. The medic that treats that responsibility cavalierly does harm to the patient and to what many people hope will some day be a profession.


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## firetender (Jul 7, 2011)

Too Old To Work said:


> Actually, I'm basing it on several posts of his. QUOTE]
> 
> 
> In that case, please keep your comments limited to the actual post you are referring to. From this point on, further comments of this kind will be considered violation of our "Be Polite" rule.


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