# What should have been done?



## ClarkEMS (Jan 21, 2009)

I had a patient today who called campus EMS because of right side abdominal pain. On arrival the patient was conscious and alert and it seemed like the only problem was the pain which was seemingly very extreme. We took vitals and tried to talk the patient into going on an ambulance (protocol for us), but the patient refused and we called a taxi. The patient walked down the stairs with us just fine but once we reached the bottom floor the patient crashed. The patient was sweating bullets and looked so pale, a complete difference from when we first arrived. Needless to say I got a BLS truck on scene and patient was transported, but I can't help but think that we could have handled this better...any suggestions?


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## Epi-do (Jan 21, 2009)

If the patient was A&Ox3 and you explained the possible complications associated with their complaint, there really isn't anything you can do.  It sounds to me like you did all you could, including getting the ambulance there once the patient's condition changed.


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## ClarkEMS (Jan 21, 2009)

I agree, especially when me and my two partners were going over what happened we decided that we did everything we could at the time. The worry was more that we might have aggravated whatever it was that was bothering the patient in moving them down stairs. Though, once again, I don't think there was any other way, but the patient just absolutely deteriorated when we reached the bottom floor. Vitals were strong, but the patient looked sweaty and pale and was most definitely in a lot of pain...


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## medic417 (Jan 21, 2009)

As long as you actually tried to convince person to go and did not hint that they were fine and could go on their own and they were were competent adult nothing else you can do.


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## VentMedic (Jan 21, 2009)

ClarkEMS said:


> I had a *patient today who called* campus EMS because of right side abdominal pain.


 
The patient called EMS? Not a bystander or Significant Other?

What was the patient's expectation of EMS? Did he just ask for an opinion or reassurance that it was nothing? 

What could you have said that may have led the patient to believe he could go by taxi if he was the one who called EMS?



> it seemed like the only problem was the pain


Did you use statements like "your vital signs are *fine*"? or "I don't think it is anything too serious" or "this is your *only* problem?". 

Was your tone casual to almost bored or serious? Body language? 

Even if you said "but I think you should still get checked out" after those statements, they may have stopped listening after they heard what they wanted to hear...reassurance that it was nothing. 

Some patients will hang on to your every word even if you don't believe what you said is a big deal. This is especially true of people having a cardiac event.



> If the patient was A&Ox3 and you explained the possible complications associated with their complaint


 
A&O x3 may mean very little in court unless you have excellent documentation or can get a signature on something that they understood what you said. Getting a signature from a witness to the conversation may also be helpful especially if it is a friend or family member who says they will see the patient follows through with your advice. 

This is why some hospital procedure and surgical consent forms have a space for the patient to write what they believe the procedure to be in their own words. Even if they just write "cut me open and may die", at least they got the highlights of conversation. You might also look at the paperwork an ED discharges a patient with. It leaves little to chance and puts the responsibility to the patient. Although, that too can be argued it is of little use in the court room for some situations.


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## medicdan (Jan 21, 2009)

Heh. Clark, we have talked about this before.... lol
On his particular campus, patients can receive a free taxi voucher if they call EMS for a non-emergency complaint, are assessed and sign a refusal. 
I agree, you couldnt have done anything different re: advising the patient of risks of refusal. You did right in calling for BLS as soon as the patient deteriorated. 
I am more interested in the underlying condition of the patient. What were the vitals? Can you recall the SAMPLE history? OPQRST? Did you palpate the abd? Do you have a way of finding out patient outcome? Were you the senior on the call? 

This could be an interesting case review for your entire corps. Its a good reminder both that patients can turn at any time, and a good way to review the acceptance of refusals.


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## VentMedic (Jan 21, 2009)

emt-student said:


> On his particular campus, patients can receive a free taxi voucher if they call EMS for a non-emergency complaint, are assessed and sign a refusal.


 
That can be another point that any legal person could bring up.

At anytime did you imply a FREE taxi vs an ambulance that will cost more than college student makes in a couple of months?


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## ClarkEMS (Jan 21, 2009)

Yeah, which they did, the patient refused after I said it would be a good idea if they were to take an ambulance which was fine by me, though my partners were concerned, I knew that the patient was competent and I talked about the ambulance a few times and all those times they said no. After seeing deterioration I sat down with her and said that if she went in a taxi she might not be seen right away and that at least in an ambulance she could be watched over and would go straight in. That turned her, plus I think she was in excruciating pain. I was mainly on the radio with dispatch, I should have caught this, but I didn't until after it was already done that my partner did not check respiration nor palpate abd. The vitals were fine though, solid BP, Pulse was not bad. I checked respiration the second time around with vitals because my partner didn't seem interested in taking them and found that she had what looked to be slight shallow breathing and I asked her about it and she said it wasn't painful to breath, though she did mention that she did have a little trouble, but she was speaking clear sentences to me, she wasn't short of breath and her resp count was perfect. The patients pupils were fine until she got downstairs when they suddenly dilated. The SAMPLE checked out, nothing jumped out at me from what she said other than this was the first time it had happened, the lack of food eaten, and the amount of pain. In the end, I believe my only mistake was not watching my partner, who should have been looking at breathing. I was senior on the scene which is why I am running this 20 times over in my head of what I could have done wrong and how to do better next time. This was my first call back on campus and my first as a senior member so it was a little stressful to say the least.


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## ClarkEMS (Jan 21, 2009)

VentMedic said:


> That can be another point that any legal person could bring up.
> 
> At anytime did you imply a FREE taxi vs an ambulance that will cost more than college student makes in a couple of months?



Yes, I explained that the taxi was free, which I think at first sounded great to her, and the ambulance is covered through Clark insurance. when she turned bad though, I explained her options, the taxi she knew was free, but it didn't guarantee that she could get care immediately if needed. It was when she turned for the worst that I said an ambulance might be a good idea for her considering the amount of pain and the fact that she did not look like she was doing well at all. And I still kept the refusal form with the report to cover all my bases. Oh and her two friends as well as two other EMS members were there to witness the signing of the refusal so there was no problem on that front legally.


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## Veneficus (Jan 21, 2009)

just some points to consider,

a female of childbearing age complaining of R abd pain, I don't think breathing rate was going to make much difference in your treatment. 

Acute surgical conditions would be more along the lines of thinking. Nobody is asking you to diagnose the problem, but I always like to plan for the worst and go from there.

ruptured ectopic pregnancy
abrupto placenta
ruptured appendix
ruptured ovarian cyst
perforated bowel
or the college campus issue of acute liver failure.

would be my top list. Not exactly diagnosable in the field, but certainly life threatening and things I hope basics are at least aware of.


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## VentMedic (Jan 21, 2009)

> Yeah, which they did, *the patient refused after I said it would be a good idea if they were to take an ambulance which was fine by me, though my partners were concerned, *


 


ClarkEMS said:


> Yes, *I explained that the taxi was free, which I think at first sounded great to her, and the ambulance is covered through Clark insurance. when she turned bad though, I explained her options, the taxi she knew was free, but it didn't guarantee that she could get care immediately if needed.* It was when she turned for the worst that I said an ambulance might be a good idea for her considering the amount of pain and the fact that she did not look like she was doing well at all. And I still kept the refusal form with the report to cover all my bases. Oh and her two friends as well as two other EMS members were there to witness the signing of the *refusal so there was no problem on that front legally*.


 
No, the way you have presented it here, you essentially talked her into the taxi. That is how it will be presented.



> Oh and her two friends


 
Her other two friends may be very helpful in backing that up. 


Your show of indifference by "which is fine by me" may also be used if it was picked up on by either the patient, bystanders or your co-workers.

Your job is not to be a financial consultant waving a free taxi voucher. You should have discussed only the medical situation and then presented the options. It is not easy to back paddle once you've sold the patient on an idea and the fact that they may actually have trusted you as a medical authority. 

Review Veneficus' post. Review the many diseases that can happen to a young person. Bad things happen to the young also.

Review what your refusal form says. Does it say refusal of medical care? Against medical advice? This patient was not refusing medical care. Apparently she was just taking your advice and once the ambulance was presented by YOU as what she SHOULD do, there is not really a "refusal" here.


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## ClarkEMS (Jan 21, 2009)

Veneficus said:


> just some points to consider,
> 
> a female of childbearing age complaining of R abd pain, I don't think breathing rate was going to make much difference in your treatment.
> 
> ...



Well, there is the first problem, we aren't all EMTs on the squad. A bunch of us are being put through EMT training through the school which is what I am doing, otherwise everyone is a first responder. I immediately thought of pregnancy problems or appendix and a few other things which is why in the end when she turned bad I called BLS instead of sending her in the taxi.


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## VentMedic (Jan 21, 2009)

ClarkEMS said:


> Well, there is the first problem, we aren't all EMTs on the squad. A bunch of us are being put through EMT training through the school which is what I am doing, otherwise everyone is a first responder. *I immediately thought of pregnancy problems or appendix and a few other things which is why in the end when she turned bad I called BLS instead of sending her in the taxi*.


 
I would love to be an attorney for this patient. Keep your stories straight. You would be very easy to trip up in a legal depo.



ClarkEMS said:


> I agree, especially when me and my two partners were going over what happened we decided that we did everything we could at the time. The worry was more that *we might have aggravated whatever it was that was bothering the patient in moving them down stairs.* Though, once again, I don't think there was any other way, but the patient just absolutely deteriorated when we reached the bottom floor. Vitals were strong, but the patient looked sweaty and pale and was most definitely in a lot of pain...


 


> *Yes, I explained that the taxi was free, which I think at first sounded great to her, and the ambulance is covered through Clark insurance. when she turned bad though, I explained her options, the taxi she knew was free, but it didn't guarantee that she could get care immediately if needed. It was when she turned for the worst* that I said an ambulance might be a good idea for her considering the amount of pain and the fact that she did not look like she was doing well at all.


 


> The vitals were fine though, solid BP, Pulse was not bad. I checked respiration the second time around with vitals because my partner didn't seem interested in taking them and found that she had *what looked to be slight shallow breathing and I asked her about it and she said it wasn't painful to breath, though she did mention that she did have a little trouble, but she was speaking clear sentences to me, she wasn't short of breath and her resp count was perfect. The patients pupils were fine until she got downstairs when they suddenly dilated.* *The SAMPLE checked out, nothing jumped out at me from what she said other than this was the first time it had happened, the lack of food eaten, and the amount of pain. In the end, I believe my only mistake was not watching my partner, who should have been looking at breathing. *I was senior on the scene which is why I am running this 20 times over in my head of what I could have done wrong and how to do better next time.


 
Since you are only a First Responder, let this be a good lesson to get medical help and stop putting all your bets on a piece of paper. You are NOT qualified to assess *medical emergencies* as to whether they need treatment immediately or not.


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## Veneficus (Jan 21, 2009)

ClarkEMS said:


> Well, there is the first problem, we aren't all EMTs on the squad. A bunch of us are being put through EMT training through the school which is what I am doing, otherwise everyone is a first responder. I immediately thought of pregnancy problems or appendix and a few other things which is why in the end when she turned bad I called BLS instead of sending her in the taxi.



Wasn't trying to lay into you or anything, but give you some things to think about. You must forgive me as I have not taught first responders since 2003 and basics since 2004. I have no idea what they are teaching in those classes now a days. But I do hope that it is the names of life threatening emergencies and when in doubt call 911. 

Not singling you out, but I do worry your system puts you at undue risk. First responders getting signed refusals seems a bit shakey to me. How could you possibly defend you made clear the nature or seriousness of the patient condition? I only know about you what you have written here, but you seem like a decent person and i'd hate to see you wind up in hot water over short sightedness on the part of your system.

The refusal may not have been because you convinced her to, but in western society you must be aware that especially in front of peers, young adults may not be completely forthcoming with information that will be medically pertinant. I think it might be safer calling a squad as soon as you think it is an emergency.

just my opinion, but you know what opinions are like.


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## triemal04 (Jan 21, 2009)

So...you have essentially no medical knowledge, education, or training, and you are responding to people that otherwise would be getting a responce by qualified paramedics?  This is why campus EMS is a worthless idea unless they are ONLY acting as first responders for a couple of minutes until an ambulance arrives.  

The abd can be a complicated enough area for an experienced provider, let alone someone in your position.  This is evidenced nicely by your thought that all you did wrong was not watch your partner.  Nothing personal, but there you go.  

Just out of curiosity, after the pt "deteriorated" why did you call for a BLS ambulance?  What do you really think they would do for this girl that you couldn't?  Hint- the answer is nothing.


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## knxemt1983 (Jan 22, 2009)

*just a thought...*



Veneficus said:


> Not singling you out, but I do worry your system puts you at undue risk. First responders getting signed refusals seems a bit shakey to me.



off topic but here's something to suggest for future cases. At my first squad, I was only a FR, and they sent us out on stuff but there were two backups. 
1. we had an Ambulance coming
2. if we canceled the ambulance and it wasn't a totally false call, we had to contact med control and get there permission for a refusal AMA, and 9 out of 10 times the doc would talk to the pt.

just a thought I had, don't know how feasible it is where you are though


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## knxemt1983 (Jan 22, 2009)

triemal04 said:


> So...you have essentially no medical knowledge, education, or training, and you are responding to people that otherwise would be getting a responce by qualified paramedics?  This is why campus EMS is a worthless idea unless they are ONLY acting as first responders for a couple of minutes until an ambulance arrives.
> 
> The abd can be a complicated enough area for an experienced provider, let alone someone in your position.  This is evidenced nicely by your thought that all you did wrong was not watch your partner.  Nothing personal, but there you go.
> 
> Just out of curiosity, after the pt "deteriorated" why did you call for a BLS ambulance?  What do you really think they would do for this girl that you couldn't?  Hint- the answer is nothing.



seriously? he's a first responder, probably new to the field and at least he came here to learn what went wrong, cut him some slack. I agree it was wrong, and mistakes were made but it's a learning process, I was there in his shoes once, as I;m sure you were too, unless your one of those medics who thinks they never made a mistake, boy I know I have made some, but I;ve learned from each and every one, and thankfully no pt was harmed seriously in the process.

to the original poster, what i would have done is this:
-called for a ambulance immediately 
-not worried about money or insurance, that's not the issue at hand
-advised the pt of the complexity, and importance of the ABD organs
-advised them that time could/ is of the essence and advanced test are needed
REMEMBER
-if she was still refusing to go let me ambulance come on in, and evaluate her
-basically do everything you can to cover your rump, remember we can will and should be held accountable to our decisions
- always refer to higher medical training if you're unsure
-always watch your partner, especially in an unsafe situation (not that this was, just a soapbox of mine
-whether you asses or your partner asseses, make sure it is complete thorough and sytematic. I let my emt partner assess just about every pt, but I listen to everything she ask and says and point things out as she goes. thats something we've worked on over time, but remember, it's your license and your caboose on the line too, saying I wasn't watching my partner is not a valid reason in court. 

just some info for ya.


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## Veneficus (Jan 22, 2009)

knxemt1983 said:


> off topic but here's something to suggest for future cases. At my first squad, I was only a FR, and they sent us out on stuff but there were two backups.
> 1. we had an Ambulance coming
> 2. if we canceled the ambulance and it wasn't a totally false call, we had to contact med control and get there permission for a refusal AMA, and 9 out of 10 times the doc would talk to the pt.
> 
> just a thought I had, don't know how feasible it is where you are though



The point you make here is that the patient usually would speak to the physician. That is very different from a first responder explaining to a patient conditions and consequences for not gong by ambulance. It could be argued that the FR didn't provide complete or proper information to make an informed decision to refuse. I do not hold the provider at fault, but the system that allows or encourages FRs to hand out taxi vouchers or accept refusals based on their advice to a patient puts the provider at significant legal risk.

I think FRs and campus EMS have valid roles to play, but the system must be set up properly to provide patient care as well as have legal backing for providers. As vent pointed out, if this girl files suit, these providers most likely would lose in a big way.


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## Labareda (Jan 22, 2009)

Everyone makes mistakes. There is no perfect EMT, there is no perfect Paramedic as there is no perfect Nurse. For christ sake there is no perfect Medic either. 
You should have called the Ambulance right away, even if the vital signs where fine you should have told her that she needed transportation and that you would have to call an ambulance. Even if it would cost to her, at leas you would have been with your conscience clean. 
But what is done is done, what was her problem after all? Ever talked to her again?
Everyone makes mistakes learn from it, its the only thing that can be done now.


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## boingo (Jan 22, 2009)

How does one summon campus EMS?  Do students call the campus police, or a different number?  If they feel they need an ambulance, shouldn't they cut out the middle man and just call 911?  Just curious.


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## VentMedic (Jan 22, 2009)

knxemt1983 said:


> seriously? he's a first responder, probably new to the field and at least he came here to learn what went wrong, cut him some slack. I agree it was wrong, and mistakes were made but it's a learning process, I was there in his shoes once, as I;m sure you were too, unless your one of those medics who thinks they never made a mistake, boy I know I have made some, but I;ve learned from each and every one, and *thankfully no pt was harmed seriously in the process*.


 
We don't know if the patient was harmed or not. No harm is your assumption. The OP may not know until the girl's attorney contacts him. 

This thread should have a sterner message because the OP doesn't seem to realize what a bad situation he is in for this position of FR with no backup coming. He is relying on a piece of paper to protect him from any legal liability. This is not a bashing of him as a personal attack or his one mistake. This should have been an eye opening experience for him as his post does point to the fact he has little medical knowledge and should not have been placed into this positon with the responsibilty of determining whether at ambulance should transport or accept a refusal from a patient under questionable circumstances. 

By this statement, he still has a lot to learn. 



> *I believe my only mistake was not watching my partner, *


If that was my daughter, after learning she was going to be okay, I would focus on getting an attorney if nothing else other than to make a change in that system or a change in attitudes. There should be an expectation about the level of care coming to your assistance when you dial 911 or even campus EMS. I would be questioning what type of emergency medical care our kids have access to in college. If the only care you are getting is a FR and the public is putting their trust unknowingly into their hands to make determinations of transport or not, that system is flawed. Is it too much to have even an EMT-B available? I would hope the majority of the country does provide at least an EMT-B when they use the term "EMS". 

What happens when they get a patient with "the flu" and no transport is done except maybe to wait for a taxi? What do you think are the consequences of meningitis on a college campus*?*

I would rather have the OP start asking the questions that have been presented here to his superiors and to review his P&P book rather than spending his senior year tangled up in a legal case. 

There are some posts where hand holding and soft, gentle words are necessary. This is not one of them. 

Yes, Paramedics, Nurses and RRTs do make mistakes and the consequences can be very serious for both the patient and the provider.  

Again, EMS is about patients and their lives. Regardless of your level, one must think about providing the best medical care possible for the patient.


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## ClarkEMS (Jan 22, 2009)

We never find out the end result with our patients, but I looked up all the symptoms last night and did some research into some possible things that it could have been and I am most definitely sure that it was appendicitis. I will never know for sure, but every symptom I saw in the patient was listed under appendicitis. I think in trying to explain this case I wasn't very clear on what exactly happened as is the case usually when trying to remember every detail. I agree mistakes were made which is why I put this up here in the first place because I like getting feedback and I don't think that I am a medical god who knows all and never makes mistakes. I am a FR in training to be an EMT on a campus squad that I already know has saved lives with their quick response time and contact with ambulance service. We are probably the most under appreciated, ignored, and put down medical group, but we still go out there and try to help people and organize a successful emergency care situation. I want to make my squad better and make my response to situations better, hence going to an EMT class. This was my first time in a position of command on the squad and I think I did a pretty good job in the circumstances and I understand areas of improvement which I will definitely take into consideration for my next call. Thank you EMTLife because without you guys I wouldn't have a place to get good advice for the future.


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## medicdan (Jan 22, 2009)

VentMedic said:


> We don't know if the patient was harmed or not. No harm is your assumption. The OP may not know until the girl's attorney contacts him.
> 
> This thread should have a sterner message because the OP doesn't seem to realize what a bad situation he is in for this position of FR with no backup coming. He is relying on a piece of paper to protect him from any legal liability. This is not a bashing of him as a personal attack or his one mistake. This should have been an eye opening experience for him as his post does point to the fact he has little medical knowledge and should not have been placed into this positon with the responsibilty of determining whether at ambulance should transport or accept a refusal from a patient under questionable circumstances.
> 
> ...



Okay, I am going to take a stab at responding to this. I know ClarkEMS well, know his campus, and have a good sense of campus EMS as a whole from my own campus.

Clark runs an all-FR service, and the understanding under which they accept RMAs is that they say, "I have no way of diagnosing what is/could be wrong with you right now. You need to be assessed by an ER Physician, and recieve care in an ER. We are happy to call an ambulance for you, and you will be transported to the hospital (0.7 miles away), or you can sign here, refusing medical attention/urgent transportation to the ER. For all I know, without this assessment and treatment, your condition may worsen, and you may die." 

If the patient signs, the campus police department likes to make sure that the student gets some medical attention, so will provide a taxi to get the student to the hospital. That is separate from EMS. 

ClarkEMS functions as a QRS/EFR, not an ambulance service. They provide quick response times, care for minor injuries not requiring transport, and, after dispatching BLS/ALS, provide care on scene to treat life threats. 

As far as I understand it, there is a standard BLS response for every call, and the truck keeps coming unless they are canceled by the FR crew. In that case, the FR crew DOES have a backup coming, BLS at the minimum. It's also worth noting that the majority of the corps is now enrolled in an EMT course, and they have aspirations, over time, to create a BLS service. They are working to increase their communal knowledge, constantly working to improve the patient care provided. 

I know to you, campus EMS appears as pure amateurs frolicking with patient care under the guise of EMS, but on most campuses, there is real leadership, real call and case review, real medical direction, real protocols, and calls that are more various than just drunk students. 

The Campus EMS group I am associated with takes education seriously. We conduct written and skill reviews of all members regularly, making sure that all members maintain rarely-used skills and knowledge. We offer a different 2-3 hour continuing education class each week. Twice a year, we simulate an MCI or large MVA or gas leak, etc, and bring in the entire corps as responders. As well, many of our mid- and upper- level members work off campus, and in fact, a requirement for promotion is a certain amount of off-campus experience. My service has an ambulance license from the state—we are accountable to them, we were inspected two weeks ago. 

Again, no more volly debate…I am happy to have a discussion about the value or merits of college EMS squads, but on a separate discussion, away from this case review.


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## Sapphyre (Jan 22, 2009)

ClarkEMS said:


> , but I looked up all the symptoms last night and did some research into some possible things that it could have been and I am most definitely sure that it was appendicitis. I will never know for sure, but every symptom I saw in the patient was listed under appendicitis.



I'm going to keep my opinion of campus EMS, and First Responders being about to make decisions as to whether EMS is needed to myself....

But, the above quote needs to be addressed.   There is NO way you can be most definitely sure that someone has appendicitis.  I couple years ago I had 3 nurses, 2 ER IM/GP docs and 2 surgeons absolutely convinced I had appendicitis.  When they got inside to take care of it, I had yet another ruptured ovarian cyst.  Even the doctors in the hospital with access to a lab, and imaging often times can't be sure.  That is why we don't get to decide that it's "just" anything....


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## VentMedic (Jan 22, 2009)

emt-student said:


> As far as I understand it, there is a standard BLS response for every call, and *the truck keeps coming unless they are* canceled by the FR crew. In that case, the FR crew DOES have a backup coming, BLS at the minimum. It's also worth noting that the majority of the corps is now enrolled in an EMT course, and they have aspirations, over time, to create a BLS service. They are working to increase their communal knowledge, constantly working to improve the patient care provided.


 
You contradict yourself here.


> ClarkEMS functions as a QRS/EFR, not an ambulance service. They provide quick response times, care for minor injuries not requiring transport, and, *after dispatching BLS/ALS,* provide care on scene to treat life threats.


 
How much time is wasted and other mistakes have been made by relying on a FR to determine the need for an ambulance before dispatching it? 

If the ambulance had been dispatched along with the FRs in this scenario, we probably wouldn't be having this discussion. 

Read how the OP explained it.




> Clark runs an all-FR service, and the understanding under which they accept RMAs


 RMA - Refuse Medical Advice? If the patient is accepting your suggestion to take a taxi, they are *taking your medical advice*. The FR "advised" me to take a taxi because it was free. That is still advice to get one to the ED. It is not a refusal of care. By suggesting the patient take a taxi, you have made the assessment that no emergent care is needed. Thus, the patient technically can not refuse urgent care since you have determined there is no need for it. 

Read and understand your forms. 



emt-student said:


> Again, no more volly debate…I am happy to have a discussion about the value or merits of college EMS squads, but on a separate discussion, away from this case review.


 
Volly? Why do you want to start a volly argument?

Even the majority of the volly systems have at least EMT-Bs.

My point is that a FR is not educated or trained well enough to be making medical decisions for what type of transport or getting refusals for medical emergencies regardless of whatever little liability disclaimer speech is used to get an RMA. 

You list yourself as an emt-student or now EMT-B. How qualified are you to judge whether a system is providing adequate medical expertise? 

The argument in EMS has been with people that have little medical knowledge making the decisions for who and what provides EMS. This includes the FD vs EMS debate. And now, we have members of the EMS community arguing for even a lower standard of care than EMT-B? Why bother advancing your education if you are already defending this standard of care? You see to think it is functioning fine as it is.

College students shouldn't be treated as second class citizens and should have access to at least an EMT-B in emergencies especially if the ambulance is to be dispatched later. That should just be the minimum requirement.


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## BossyCow (Jan 22, 2009)

The reason we write r/o on the reports under the assessment portion is because we don't know and can't know what's wrong. Especially in an ABD pain case. 

I've had cases I "Knew" were appendicitus that weren't and hot appendices that I guessed as kidney pain. I've seen appendicitus radiating to the left side, presenting as back pain and rebound tenderness showing up in a case of stomach flu/gastritis. Bellies are mysteries. Without the ultrasound, lab results and other miracles of modern medicine, belly issues cannot be diagnosed in the field... period.


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## Veneficus (Jan 22, 2009)

BossyCow said:


> The reason we write r/o on the reports under the assessment portion is because we don't know and can't know what's wrong. Especially in an ABD pain case.
> 
> I've had cases I "Knew" were appendicitus that weren't and hot appendices that I guessed as kidney pain. I've seen appendicitus radiating to the left side, presenting as back pain and rebound tenderness showing up in a case of stomach flu/gastritis. Bellies are mysteries. Without the ultrasound, lab results and other miracles of modern medicine, belly issues cannot be diagnosed in the field... period.



great post.

one of my profs likes to say that 75% of all medicine is in the abd. That's a lot of stuff.


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## NebraskanPrincess (Jan 23, 2009)

This one time, I was convinced I was having a heart attack.  It went away after an hour.  The third time I had an attack I was working in the ER and bawled bravely for 1.5 hours from mid-chest pain until it went away.  Had my gallbladder taken out precisely 5 days later.

I agree.  The abdomen is weird - like a lot of the body.  Things get more complicated with the possibility of referred pain.  

ClarkEMS, good for you for wanting to learn   In the future, while your partner is doing the assessment, you may remember to pay closer attention to what they're doing to pick up on details as well.  Sometimes, if a person is in charge of strictly vitals, they will miss things the "scene commander" can pick up on by observing the patient.  It takes a lot of communication and teamwork to provide full patient care.

The money issue is a tricky thing in our economy.  It's going to get worse if the economy continues to get worse.  I was working in the ER awhile ago and was stunned to see a purple, non-breathing baby fly through the front doors with frantic parents.  They didn't want the ambulance to drive them because of the bills.  Then again, it's not just the money that's complicating things.  In emergencies, people freak out.  They don't make the best decisions and they aren't rational.  And even if it is a "minor" call, the stress of even having to dial 911 can be enormous for some people.  

I'm not bold enough nor experienced enough to be able to tell you the "right thing" to have done in this situation.  When the patient brings up money concerns to me, my standard line is, "my job is to worry about your health.  These are your vitals, this is what could possibly be happening in your body, these are the risks of your not receiving more medical treatment.  If money weren't an issue right now, what would your decision be?"  I work for a private service that probably doesn't think I'm the greatest person in the world, but I didn't choose this job because I wanted some person at the top to get richer.  And at the money I make, I know someone up there has got to be making some sort of good money 

Ultimately, all we can do is be honest with our patients about what we observe/see/are trained and provide them their options.  If they are conscious, alert, and oriented, it is not our jobs to make their decisions for them.  Coercing someone to go with you is just as bad as convincing them not to.  It's a double-edged sword.  

The best you can do is do what you can with what you have.  I have never been to the area you serve, don't know your protocols, don't know anything about your squad.  I can tell you that I serve the Siberia of America where First Responders don't have the authority to make the treat/not treat decision in our rural areas.  If they can't get EMTs to respond, our ALS unit has to make the trek out to the area even if to get a decline on our services.  I'm glad that you're studying to be an EMT as I hope it will provide you with a rich base of knowledge that will help prepare you to serve the college students you do.  Learn from experience and do it differently the next time - that's what will put you apart from many.

And heck yeah on the not treating College Students as second-class citizens.  Now, can someone do a protest on my alma mater's campus and demand the cafeteria stop serving that poison?  Ooo!  And if you could stick up for we vegetarians whom they offered tomato sandwiches to EVERY day I'd be your fan!


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## ClarkEMS (Jan 23, 2009)

Yeah, honestly, I don't know how cost became a factor in this discussion. The patient didn't choose a taxi over ambulance cause it was free, the ambulance is free too. No doubt that abd situations are tough I wasn't about to tell the patient that she had appendicitis or ectopic pregnancy or whatever, I never told her that I could diagnose her or that she had any of those things. I asked a few times if she wanted an ambulance, she refused I told her that she would have to take a taxi then which is policy and that is of no charge to her so she wouldn't be worried on that front, she signed a refusal with witnesses present, as she began to deteriorate, I sat down with her and explained that I felt it was safer to take an ambulance as she could be watched over and gotten to the hospital probably faster than a taxi which would most likely get stuck in a traffic. Mainly, I expressed that I wanted someone to be there if something happened which is what an ambulance could provide. She accepted, I radioed in, an ambulance arrived shortly thereafter, she was taken to the hospital, I happened to see her walking on campus this evening, I am sure she is fine. End of story. 

I love learning, especially about what I can do to make things better on campus for our EMS service. Thanks for the advice!


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## NebraskanPrincess (Jan 23, 2009)

Clark, I understand your frustration, but I hope you didn't perceive my suggestions as bashing you!  I apologize if you did!


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## ClarkEMS (Jan 23, 2009)

NebraskanPrincess said:


> Clark, I understand your frustration, but I hope you didn't perceive my suggestions as bashing you!  I apologize if you did!



Oh no you are fine! I appreciate what you wrote, I wrote that post before I saw yours. Thanks!


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## triemal04 (Jan 23, 2009)

knxemt1983 said:


> seriously? he's a first responder, probably new to the field and at least he came here to learn what went wrong, cut him some slack. I agree it was wrong, and mistakes were made but it's a learning process, I was there in his shoes once, as I;m sure you were too, unless your one of those medics who thinks they never made a mistake, boy I know I have made some, but I;ve learned from each and every one, and thankfully no pt was harmed seriously in the process.


Doesn't matter.  While I agree that newer people (and people who have been around for decades) will make mistakes, and that it's not always a bad thing (as long as they learn from the mistake and don't repeat it) that's not the only problem here.  

If he's that inexperienced, why was he in charge by himself?
Why was an ambulance not dispatched right off the bat?  And yes, his further posts make it pretty clear that he had to call for one AFTER contacting the pt.
Why was a BLS ambulance called for a female with abdominal pn?
Why is this inexperienced, uneducated and untrained person (sorry dude, but it's true, no offence meant) being put into a situation where he could be telling someone whether or not they need an ambulance or ER visit?

All these and more need to be answered.  The problem goes beyond ClarkEMS and to his system, as it's being displayed here.


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## medicdan (Jan 23, 2009)

Vent, lets agree to disagree. You brought up some interesting points, I have learned. Thank you.


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## Jon (Jan 23, 2009)

Clark:

What conerns me is that you folks obtained a refusal without doing a thorough assessment of your patient - you said you didn't palpate the abdomen or get a complete set of vital signs until AFTER they signed the refusal.

A true RMA - "Refusal against Medical Advice" requires a FULL assessment, probably a call to a Command physician (under my local BLS and ALS protocols it does), and lots of documentation, as well as a good expination of the risks associated with refusal to the patient.

If you don't do this - you are doing your patients a disservice... and it might come back and bite you later.


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## ClarkEMS (Jan 23, 2009)

Jon said:


> Clark:
> 
> What conerns me is that you folks obtained a refusal without doing a thorough assessment of your patient - you said you didn't palpate the abdomen or get a complete set of vital signs until AFTER they signed the refusal.
> 
> ...



Dually noted and I understand that. That is what concerned me too and this will most likely be brought up at our run review meeting with our medical director. The vitals were fine other than the fact that my partner didn't take repirations which I later took. This refusal is not a refusal of care it is a refusal to take an ambulance, in which case they are still forced to go to the hospital taxi. Next time I am going to make sure that repirations are taken and not overlooked. In the end though, due to a change in the patients condition an ambulance was called, we stayed with the patient taking more sets of vitals and watching her condition throughout this time. The ambulance took over care and she was sent to a hospital.


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## VentMedic (Jan 23, 2009)

ClarkEMS said:


> Next time I am going to make sure that repirations are taken and not overlooked. In the end though, due to a change in the patients condition an ambulance was called, we stayed with the patient taking more sets of vitals and watching her condition throughout this time. The ambulance took over care and she was sent to a hospital.


 
This is purely for educational purposes.

You have been focused on the respirations throughout this post. Was the patient having difficulty talking to you? Did you hear something suspicious in her breath sounds? 

What would you expect the respiratory rate and quality to be for a young person in pain?

What in your findings would have taken you down a different path?


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## rogersam5 (Jan 23, 2009)

When I respond to a call that has any posibility of being serious an EA is called. I have had a few sign out, and not go to the hospital. But most go, when I tell them they should. I give them a good talk about what it could be and what could happen if they don't get it treated, I have had a few arm injurys that I convinced into going ot the hospital and they ended up a lot worse they the pt. thought they would be. If I am not sure how serious it is... I tell dispach to send me an EA, they Call WEMS, WEMS shows up and the Paramedics sort out what should happen, most of the time, the pt. goes for a ride with the Paramedics. I remeber one that just wanted a ride to the hospital down the street (literaly takes 5 min to get there) but we told them that it would be a better idea to take a ride in the ambulace, they agreed, WEMS brought them to the hospital...


If your the Clark I think you are... greetings from down the street.


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## Emtgirl21 (Jan 23, 2009)

A BLS ambulance transported her....thats the part I keep tripping on. An acute abdomen requires a paramedic, an IV, oxygen, monitor, and frequent vitals. An etopic can turn deadly quickly. Not to mention its just nice to have the option to give Zofran( or antimetic of your companys choice) vs having someone vomit all over your truck.


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## Veneficus (Jan 23, 2009)

Emtgirl21 said:


> A BLS ambulance transported her....thats the part I keep tripping on. An acute abdomen requires a paramedic, an IV, oxygen, monitor, and frequent vitals. An etopic can turn deadly quickly. Not to mention its just nice to have the option to give Zofran( or antimetic of your companys choice) vs having someone vomit all over your truck.



Not trying to be smart or derogatory, but if suspected a ruptured ectopic pregnancy is a surgical emergency; there is nothing ALS is going to do for that. Fluid is not going to change outcome.  If the BLS unit can get the pt to the hospital quicker, the BLS unit is the best option.

A pt. with a tubal pregnancy that has not ruptured can be treated medically in some cases. Nothing ALS does is going to make a difference there either

In either case vomit is of no concern.


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## Emtgirl21 (Jan 24, 2009)

So are you saying that you would not preform any ALS skills on said pt?


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## Veneficus (Jan 24, 2009)

Emtgirl21 said:


> So are you saying that you would not preform any ALS skills on said pt?



I am saying if I thought the pt had an ectopic pregnancy I would not delay transport to wait for an ALS unit to arrive if a BLS unit was already on scene and capable of  immediate transport.

If I was an ALS unit that responded as the initial unit I would start a line in addition to other treatments based on my findings. In the event of a suspected ectopic I would make a determination if I was going to run fluid based on clinical signs of hemostasis. But either way I doubt the fluid would be a determining factor in outcome.(unless it was a massive hemorrhage in which case a fluid bolus would likely make it worse.) I would be more concerned about slowing or stopping the bleed. (which could also be done by an astute basic while in route to surgery)

I maintain slowing or stopping a bleed and rapid transport would be more effective in a ruptured ectopic pregnancy than any ALS procedure available on most squads in the US.

I also am not too bad at Hx and PE and could probably narrow down the diagnosis a little closer than abd pain as presented by the OP, which would determine exactly what treatment I thought appropriate in the event it was not likely an ectopic.


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## medic417 (Jan 24, 2009)

This could all be avoided if only ALS responded in the beginning.


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## triemal04 (Jan 24, 2009)

medic417 said:


> This could all be avoided if only ALS responded in the beginning.


Ding ding ding!  We have a winner!


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## daedalus (Jan 24, 2009)

Veneficus said:


> I am saying if I thought the pt had an ectopic pregnancy I would not delay transport to wait for an ALS unit to arrive if a BLS unit was already on scene and capable of  immediate transport.
> 
> If I was an ALS unit that responded as the initial unit I would start a line in addition to other treatments based on my findings. In the event of a suspected ectopic I would make a determination if I was going to run fluid based on clinical signs of hemostasis. But either way I doubt the fluid would be a determining factor in outcome.(unless it was a massive hemorrhage in which case a fluid bolus would likely make it worse.) I would be more concerned about slowing or stopping the bleed. (which could also be done by an astute basic while in route to surgery)
> 
> ...



Right.

ALS "skills" would not make a measurable benefit in outcome for a rupturing ectopic pregnancy. If I was an ALS unit, a line would be started en route, but really only so the nurse would not have to do it. Oxygen and a monitor are going to do jack as well. This is just one of those emergencies that require diesel bolus even if it is just BLS transport. If BLS could get her to the hospital faster than ALS, so be it. 

Paramedics should be far from offended or have their egos hurt because they cannot do anything for these patients. Even an Emergency Med physician is going to consult the surgical service.


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## VentMedic (Jan 24, 2009)

daedalus said:


> Right.
> 
> ALS "skills" would not make a measurable benefit in outcome for a rupturing ectopic pregnancy. If I was an ALS unit, a line would be started en route, but really only so the nurse would not have to do it. Oxygen and a monitor are going to do jack as well. This is just one of those emergencies that require diesel bolus even if it is just BLS transport. If BLS could get her to the hospital faster than ALS, so be it.
> 
> Paramedics should be far from offended or have their egos hurt because they cannot do anything for these patients. Even an Emergency Med physician is going to consult the surgical service.


 
The measurable part would be in the *recognition* of this being an emergency and time should not be wasted. Someone with a lower level of training may not recognize this. 

The same argument could be used for a trauma. ALS skills may not be utilized but the knowledge to know it is not a time for "stay and play" is useful as are the skills/education if something needs to be done.

The ALS or BLS attitude needs to vanish and medicine should prevail. A doctor may examine a patient like this with all seriousness but will probably be relieved to tell the patient it is something relatively simple rather than an etopic pregnancy.


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## medic417 (Jan 24, 2009)

daedalus said:


> Right.
> 
> ALS "skills" would not make a measurable benefit in outcome for a rupturing ectopic pregnancy. If I was an ALS unit, a line would be started en route, but really only so the nurse would not have to do it. Oxygen and a monitor are going to do jack as well. This is just one of those emergencies that require diesel bolus even if it is just BLS transport. If BLS could get her to the hospital faster than ALS, so be it.
> 
> Paramedics should be far from offended or have their egos hurt because they cannot do anything for these patients. Even an Emergency Med physician is going to consult the surgical service.



"diesel bolus"  Needs to be stricken from EMS terminology.   The few seconds saved by driving at high rates of speed, blowing intersections etc do no good and actually endanger all.


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## Ridryder911 (Jan 24, 2009)

Again, it is an ALS call. Ruptured ectopic pregnancy is life threatening. Patients can develop shock syndromes and is one of the few situations fluid therapy can be helpful. Agreed, early recognition is the key and I have yet seen very many of those at the BLS level recognize such. 

I agree diesel medicine is a horrible analogy and should never be spoke of. Expeditious treatment and transfer should definitely be seek out but one should never imply over zealous transporting. Consulting with local medical control and advising the physician so they can possibly alert appropriate consults and surgical crews. 

R/r911


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## daedalus (Jan 25, 2009)

Ridryder911 said:


> Again, it is an ALS call. Ruptured ectopic pregnancy is life threatening. Patients can develop shock syndromes and is one of the few situations fluid therapy can be helpful. Agreed, early recognition is the key and I have yet seen very many of those at the BLS level recognize such.
> 
> I agree diesel medicine is a horrible analogy and should never be spoke of. Expeditious treatment and transfer should definitely be seek out but one should never imply over zealous transporting. Consulting with local medical control and advising the physician so they can possibly alert appropriate consults and surgical crews.
> 
> R/r911


Diesel bolus hardly means reckless driving or even code 3 transport. At least in my book. It just means driving the rig to the hospital and not telling someone its just gas and sign out AMA. 

Is it an ALS call? You bet! Should most everything be ALS in the first place? Even better! 

But in this case, its best just to get the patient to the hospital. EMTs may fail to recognize this. I said may, I know there are quite a few capable providers on this forum, but many are not like you.


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## Veneficus (Jan 25, 2009)

Ridryder911 said:


> Again, it is an ALS call. Ruptured ectopic pregnancy is life threatening. Patients can develop shock syndromes and is one of the few situations fluid therapy can be helpful. Agreed, early recognition is the key and I have yet seen very many of those at the BLS level recognize such.



Rid,

The key here I think is "may be helpful" which would depend on the extent of the bleed. for some time now the surgical community has been promoting more judicious use of fluid for hemorrhage. In the last presentation I have heard, fluid and permissive hypotension have no difference in outcome for bleeding from blunt trauma. (which I would argue is what a ruptured tube is.)  Crystallod will have no appreciable effect. 

I also agree with Daedalus, neither will a heart monitor or any other "ALS device" carried prehospital. Some basic maneuver, like direct pressure, will reduce the size of the cavity as well as increase pressure outside of the vessles which could help to control the bleed. In the preshospital setting I think it would be more useful an itervention that salt water in a vein for this pathology. 




Ridryder911 said:


> I agree diesel medicine is a horrible analogy and should never be spoke of. Expeditious treatment and transfer should definitely be seek out but one should never imply over zealous transporting. Consulting with local medical control and advising the physician so they can possibly alert appropriate consults and surgical crews.
> 
> R/r911



Agree in full. Drive safely!


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## redcrossemt (Jan 25, 2009)

medic417 said:


> "diesel bolus"  Needs to be stricken from EMS terminology.   The few seconds saved by driving at high rates of speed, blowing intersections etc do no good and actually endanger all.



^ THANK YOU!

First, ClarkEMS, some people have been hard on you. Most of them are trying to help, though. Even if a few here don't appreciate your work, you will many times see patients who will appreciate the fast response and initial (life-saving) care you provide. I understand that you guys are volunteers trying to help, and applaud you for doing that, and for wanting to educate yourself and learn more.

Regarding this patient, any chance she was intoxicated or under the influence of other mind-altering substances?

Did you ask any questions regarding the possibility of pregnancy?

Did you explain that the ambulance is free? Why would someone in excruciating pain choose a taxi over an ambulance if both were free? 

It's not clear to me who provides the taxi vouchers...? Whatever service/department is providing the vouchers may have a huge liability.

Did this caller call 911? Public safety's non-emergency number? A campus clinic or health service non-emergency number? Who dispatches you? Do they not dispatch an ambulance as well?

Did you provide any care after she "crashed"? Oxygen maybe? Was teatment for shock indicated?

I manage a non-transporting QRS/FR service at special events. If a call goes to a dispatch center (via 911 or direct phone), then an ALS ambulance is dispatched simultaneously with us. We only cancel them for bandaid calls. If they took a "cancel" from us on a medical call, and the patient got sick or died later, they could be in big trouble. We like to let them take the refusal - they have the toys, and can take on the responsibility. If we are called direct or flagged down for anything that seems like more than simple first aid in the immediate area, we find out an age, chief complaint, breathing status, and mental status then call. If we have more than a minute or two response time we request ALS rolls (non-emergently) for an unknown medical and readvise once we arrive on-scene.


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## Ridryder911 (Jan 25, 2009)

Here is a link with a good article on ectopic pregnancies. Ironically I was surprised when it was discussed traditional surgery was not recommended on such but rather laproscopy was performed even in such cases of rupture.

http://www.obgyn.net/displayarticle...res/mcgill-student-projects/ectopic-pregnancy

R/r 911


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## Veneficus (Jan 25, 2009)

good article rid


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## VentMedic (Jan 25, 2009)

Ridryder911 said:


> Ironically I was surprised when it was discussed traditional surgery was not recommended on such but rather laproscopy was performed even in such cases of rupture.
> 
> 
> R/r 911


 
If it rare to see traditional surgery in young people these. 

Besides some of the usual gallbladder and appendix, congenital heart defects, hysterectomies and AAAs are removed/repaired with minimally invasive or nontraditional procedures. Many patients are 23 hour admits after surgery and discharged the next day.


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## ClarkEMS (Jan 26, 2009)

redcrossemt said:


> ^ THANK YOU!
> 
> First, ClarkEMS, some people have been hard on you. Most of them are trying to help, though. Even if a few here don't appreciate your work, you will many times see patients who will appreciate the fast response and initial (life-saving) care you provide. I understand that you guys are volunteers trying to help, and applaud you for doing that, and for wanting to educate yourself and learn more.
> 
> ...



Yeah, I understand completely with the posts, and I appreciate the help which is why I posted this in the first place 


She wasn't intoxicated or under the influence of anything. She knew where she was, what she was doing, did not slur speech, etc. The reason she did not want to take the ambulance was because she didn't want to make a scene of it, I told her it would be best to go on an ambulance, but she refused. The Clark Police Department provide the free taxi upon notification of a refusal. The students are encouraged not to use 911 for whatever reason the University has, I am not educated on the exact reasons why students are told to call Clark Police dispatch. Once Clark dispatch gets the call they page us and we respond. Meanwhile, the MedStar is tied into our radio system so they hear what is going on and can be in direct contact with us or dispatch, generally though they just sign on to a frequency when they are notified by Clark dispatch. As far as I know, the ambulance is only dispatched along with us for certain calls on campus, all other times we get there and we get permission from the patient to get an ambulance and we call it in. Usually police are on scene to help as well. No treatment for shock was indicated. When she "crashed" I mean more that she went from being pretty normal other than the pain to sweaty with some slight paleness and clearly showing signs of extreme pain. The ambulance got to the scene so quickly that we didn't even have time to do anything more for her.


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## sarahharter (Jan 26, 2009)

i agree with many things stated on the posts above. i however do have some concerns. where i run, FR are not allowed to do pt assessments and have to be with an EMT or MEDIC. They were pretty much there to assist the EMT and drive. I also believe in ALS being dispatched initially for pretty much any call, i have been dispatched BLS and it really  should have been ALS. i have also been on calls where BLS could transport to the hospital faster than ALS could be on scene. I think that the college has a good idea but maybe they meed to expand on the concept and have emts and medics on staff. i undertsand that most of the FR are going through EMT school however i think that they should have someone with more experience and training there also. and the fact that the students dont call 911 if kinda fishy to me and if i were a parent of the student i would be questioning that. However to the FR i appriciate that you want to learn more and do help with what you can.


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## emtfarva (Feb 5, 2009)

daedalus said:


> Diesel bolus hardly means reckless driving or even code 3 transport. At least in my book. It just means driving the rig to the hospital and not telling someone its just gas and sign out AMA.
> 
> Is it an ALS call? You bet! Should most everything be ALS in the first place? Even better!
> 
> But in this case, its best just to get the patient to the hospital. EMTs may fail to recognize this. I said may, I know there are quite a few capable providers on this forum, but many are not like you.



everything is an als call, ok. My company does a 911 contract for taunton, ma 55% of the calls are of psych in nature. You as a medic want to go 7 calls a day and deal with psychs. not including grandma has a cold, the ocasional code or two or three, rectual bleeds, n&v, mvc, falls, h/a. That is a day in the life of tauton rescue. I firmly belive in tiered systems. It keeps medics free for more crital pts. and I am not saying that this case didn't need als. Part of our star of life states transport to diffentive care...


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## Ridryder911 (Feb 5, 2009)

emtfarva said:


> everything is an als call, ok. My company does a 911 contract for taunton, ma 55% of the calls are of psych in nature. You as a medic want to go 7 calls a day and deal with psychs. not including grandma has a cold, the ocasional code or two or three, rectual bleeds, n&v, mvc, falls, h/a. That is a day in the life of tauton rescue. I firmly belive in tiered systems. It keeps medics free for more crital pts. and I am not saying that this case didn't need als. Part of our star of life states transport to diffentive care...



Well, most of the calls you described needs ALS assessment and intervention. The psych, grandma with a cold maybe really pneumonia, and rectal bleeds are considered potentially life threatening. 

No one ever disclaiming definitive (check spelling) care, but what is determined as definitive care? Does all abrasions and minor lacerations need to be seen in a ER? Instead staffing two trucks or even possibly three, keep a Paramedic on one each. In the long run it is much more economical and then the patient always has access if needed. 

R/r 911


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## emtfarva (Feb 5, 2009)

Ridryder911 said:


> Well, most of the calls you described needs ALS assessment and intervention. The psych, grandma with a cold maybe really pneumonia, and rectal bleeds are considered potentially life threatening.
> 
> No one ever disclaiming definitive (check spelling) care, but what is determined as definitive care? Does all abrasions and minor lacerations need to be seen in a ER? Instead staffing two trucks or even possibly three, keep a Paramedic on one each. In the long run it is much more economical and then the patient always has access if needed.
> 
> R/r 911



I know what you are talking about. Currently Tauton staffs 2 dedicated rescuse from 08:00 to 21:00. After 21:00 they go down to 1. also we do some refusals. most of the time Fire will cancel the ambulance prior to arival for very minor cases. Unfortntly, Taunton has a lot of it's population has mental problems (as most of MA has). Most of the time a whole back hall of our local hosp is loaded with crisis Pts. also, for a truly psych pt, Als has no power other than to bls the call anyway. Mass does not let our medics chemically restraind our Pt's. and a good basic can write down r/o pneumonia also. the only thing medics can do in mass is also what basic do execpt for a line. we also have about 4-5 als transfer trucks around the area if taunton needs help, which they do quite often. (Let me get this out of the way, I CAN'T SPELL. SPELL CHECK DOES NOT WORK. Thank you) What I am saying is that a teired system might be better. Bls and als gets dispatched at the same time. Bls gets there and see's it's a als call they provide first response, package the pt for the medics and clear up for the next call. Same thing with a bls call, they can cxl the als crew and let them be clear. this also works if the als crew is at the hosp, the bls crew can start the first response or transport the pt. The whole point to ems is to get a PT THAT WANTS TO GO TO THE HOSP TO THE HOSP. WITH OR WITHOUT ALS. TRANSPORT THAT IS WHAT WE DO. WE ARE JUST A BIG TAXI CAB WITH MEDICAL TRAINING AND LIGHTS. Don't get me wrong I hate calling myself that but we are transportation. it is that simple. Now of course this system would work ok because our transport times are less than 10 min. I wouldn't know about long transtports. except the transports that go to higher level of care from another hosp. btw, or taunton ambulances are staffed at the P, I level. and most of our Als transfers are staffed at the P, b level, including my truck.


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## RESQ_5_1 (Feb 5, 2009)

Emtgirl21 said:


> A BLS ambulance transported her....thats the part I keep tripping on. An acute abdomen requires a paramedic, an IV, oxygen, monitor, and frequent vitals. An etopic can turn deadly quickly. Not to mention its just nice to have the option to give Zofran( or antimetic of your companys choice) vs having someone vomit all over your truck.



That's interesting. I work a BLS unit and have transported quite a few acute abds. And, I provided all the things you list in this post. 

Actually transported a 2 1/2 y/o male with what the hospital diagnosed as a Fecalyth (google it). The sending hospital ruled out appendicitis and sent us on a 2 hour ground transfer for a surgical consult. Everything was fine until about 25 minutes from the receiving hospital. My pt suddenly (and I mean SUDDENLY) had no abd pain. I had my partner turn on the lights and we continued hot to the hospital. We sat in the ER for 45 minutes waiting for a nurse to even look at him (after we explained what happened en route). The surgeon came down and was extremely unhappy. Turns out our little guy had appendicitis (initially ruled out by the sending facilities DOCTORS). And, it burst on our little road trip. Luckily, he turned out ok. Not that I want to toot my own horn, but I would have to say that by paying attention to my pt and a good assessment, I probably prevented something worse from happening. Unlike the "educated" personnel that assumed it was something different because that was what they were told and opted not to look for themselves.


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## emtfarva (Feb 5, 2009)

*I got off topic*

First of all I want say, Clark don't take this the wrong way. I want this comment to be a learing exp.

What you did was wrong. I know you are a first responder for a college campus. I am not dogging first responders. What you should have done and what you should do from now on is have this Pt evaled by emts or medics. Anyperson with a cc of abd pn, chest pn, head injury, AMS, major trauma should be checked out by emts or medics. (I might be missing a few things on that list. but i am sure some of my fellow emts will come up with some more and post them.) If you know about any of the above cc's when you are dispatched you should automaticlly call for an ambulance. Don't take a risk of getting sued because you let a critcal pt take a cab to a hosp and then that person dies. and please don't let a pt with abd pn walk down stairs or anywhere for that matter. don't let a chest pn pt walk either. just a few tips. like i said don't take it the wrong way. Learn from it and become better at your job.

Farva


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## emtfarva (Feb 5, 2009)

ClarkEMS said:


> Yeah, I understand completely with the posts, and I appreciate the help which is why I posted this in the first place
> 
> 
> She wasn't intoxicated or under the influence of anything. She knew where she was, what she was doing, did not slur speech, etc. The reason she did not want to take the ambulance was because she didn't want to make a scene of it, I told her it would be best to go on an ambulance, but she refused. The Clark Police Department provide the free taxi upon notification of a refusal. The students are encouraged not to use 911 for whatever reason the University has, I am not educated on the exact reasons why students are told to call Clark Police dispatch. Once Clark dispatch gets the call they page us and we respond. Meanwhile, the MedStar is tied into our radio system so they hear what is going on and can be in direct contact with us or dispatch, generally though they just sign on to a frequency when they are notified by Clark dispatch. As far as I know, the ambulance is only dispatched along with us for certain calls on campus, all other times we get there and we get permission from the patient to get an ambulance and we call it in. Usually police are on scene to help as well. No treatment for shock was indicated. When she "crashed" I mean more that she went from being pretty normal other than the pain to sweaty with some slight paleness and clearly showing signs of extreme pain. The ambulance got to the scene so quickly that we didn't even have time to do anything more for her.



one more thing, I would really look into why students are not encouraged to call 911. and like i said again if you get any complaints you are not comforable with just have the ambulance come with. Is this within your guidelines? don't let yourself get screwed over because they didn't dispatch an ambulance with you. On this case if I was a first responder I would have called a ambulance anyway. The Pt could have died before she got to the cab. don't let her decid what will cover your but. she should have been evaled by an emt or medic. let them take the heat if she refused. I think thats it...


Farva


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