Stroke patient dies...at shift turnover

[downunderwunda]

Bloom-IUEMT,

Selective quotation is an interesting thing, because IF you read my entire post, you would have found I also said

Quote:
They should not have clocked off

now I have said it 3 time you might see it was said.

I do not have the FULL & COMPLETE story. However, you are obviously more informed than I am so play judge, jury & executioner.

djmedic913,

when you said

4 minutes makes a HUGE difference. I know the article was titled Stroke Patient, but the article said possible heart attack.

You are right with a heart attack, however, with a CVA (Damn I used the proper term again) the rate of necrosis (damn another proper medical term) & the rate of metabolism (oh no another one) mean that reardless there will be problems, the question is how much damage. 4 minutes is negligable. 2 Hours is important. 2 Hours to determine if it is Haemhorragis or Ischaemic & thrombolyasis (the proper medical terms keep flowing) can take place in a controlled environment.

But hey, why would we want to consider reality or look at the whole story. I have seen people crucified in te media from a story written on haf (or less) the facts when the reality was completley different. Dont be to quick to judge.

There is one aurentee I will promise you here. If the 2 Officers are found to be negligent by an investigation looking at all of the evidence, it will be fron page news, a huge story, but if they are not found negligent, we will hear nothin more of it. The paper will not publish a retraction, an apology.

But dont worry uys, you have already made up your minds that they are guilty based on a newspaper report.

 

[Scott33]

Wanda.

I spend most of my forum time on a UK ambulance site, as that is where I am originally from.

Unfortunately, the general consensus of opinion from some of the UK bods who work with the people involved, seems to be that the events did happen just as reported (not just in the News of the world tabloid rag, but also the BBC news and the broadsheets).

I can only assume they may have thought the patient was stable enough at the time, to switch crew (perhaps a TIA which had resolved, and before there were any signs of the cardiac event to follow), but all it takes is one moment of shortsightedness to ruin ones career.

Needless to say though, for whatever reason it does appear like they hung themselves out to dry here, and all affected parties will be no doubt be fired. The paramedic, who was the driver, will also probably end up losing his HPC registration, and therefor will never be able to work again in that capacity.

Sorry, I have little sympathy for them. Bad, bad judgement and a lesson to us all.

 

[ffemt8978]

Wanda.

I spend most of my forum time on a UK ambulance site, as that is where I am originally from.

Unfortunately, the general consensus of opinion from some of the UK bods who work with the people involved, seems to be that the events did happen just as reported (not just in the News of the world tabloid rag, but also the BBC news and the broadsheets).

I can only assume they may have thought the patient was stable enough at the time, to switch crew (perhaps a TIA which had resolved, and before there were any signs of the cardiac event to follow), but all it takes is one moment of shortsightedness to ruin ones career.

Needless to say though, for whatever reason it does appear like they hung themselves out to dry here, and all affected parties will be no doubt be fired. The paramedic, who was the driver, will also probably end up losing his HPC registration, and therefor will never be able to work again in that capacity.

Sorry, I have little sympathy for them. Bad, bad judgement and a lesson to us all.

So the medic was the driver and the EMT was attending the CVA/cardiac patient?

 

[Scott33]

So the medic was the driver and the EMT was attending the CVA/cardiac patient?

Apparently so.

 

[Bloom-IUEMT]

Calm down Crocodile Dundee-- don't ever say 4 minutes is negligible. Ever. If that's the way you treat your patients I feel sorry for them. Based on the size and location of the CVA it can make a big difference. And what if it made a small difference?? Wouldn't you want your patient to have the best possible outcome and quality of life?
I'm not making a judgment on those medics because as you say, I don't have all the facts. But I find hard to believe that any excuse can warrant the actions these particular medics took. Who knows, maybe I'll be surprised but I doubt it.
And its thrombolysis, not thrombolyasis. If you are going to be smug about using proper medical terms, be sure they are indeed the proper medical term.

 

[rescuepoppy]

The extra 4 minutes may or may not have made a difference. But the problem for me is that you should not make a detour to your station to clock out just because you are on over-time to find out. I know that a lot of areas are taking efforts to keep over-time to a minimum. However I doubt if management would want an employee to shift change during a transport of this nature to prevent a little over-time. They understand that in this business we can't always stay right up to the minute on when we clock out. I agree with the suspension until they can investigate and sort out all of the details before a final decision is made in the matter.

 

[ffemt8978]

Calm down Crocodile Dundee-- don't ever say 4 minutes is negligible. Ever. If that's the way you treat your patients I feel sorry for them. Based on the size and location of the CVA it can make a big difference. And what if it made a small difference?? Wouldn't you want your patient to have the best possible outcome and quality of life?
I'm not making a judgment on those medics because as you say, I don't have all the facts. But I find hard to believe that any excuse can warrant the actions these particular medics took. Who knows, maybe I'll be surprised but I doubt it.
And its thrombolysis, not thrombolyasis. If you are going to be smug about using proper medical terms, be sure they are indeed the proper medical term.

4 minutes is negligible around here...with hour long transport times to the hospital. Or, are you suggesting that we need to run code to the hospital for every patient because every second counts? :wacko:

But here's the deal, according to published reports to date, this crew FAILED in two aspects. 1) They detoured to perform a shift change with a deteriorating patient, and 2) The medic was driving and the EMT was performing patient care with said patient.

Would the 4 minutes have made a difference? We'll never know for sure. Would the patient be alive if the medic had been attending him instead of the EMT? Who knows. You can bet these are the two points that will be hammered on in the subsequent lawsuit, though.

 

[Bloom-IUEMT]

4 minutes is negligible around here...with hour long transport times to the hospital. Or, are you suggesting that we need to run code to the hospital for every patient because every second counts? :wacko:

For a stroke patient you should always run code 3 or emergent. Doesn't your jurisdiction do that? Every minute counts when your dealing with infarctions.

 

[djmedic913]

For a stroke patient you should always run code 3 or emergent. Doesn't your jurisdiction do that? Every minute counts when your dealing with infarctions.

Run hot if you are still under the 3 hr window and depending on the hospital you are taking them to (If they are designated a Stroke Center there is 3, 6, 12 hour window but the regular hospitals it is only a 3 hr window). and if you can't get them to the hospital inside 2 hours of onset, it is not worth running hot...they need about 1 hour get everything set before administering thrombolytics(ie. blood tests, CT scan, etc.)

I agree run hot if you can make the window, but if you can not, there is no need to jeopardize your patient, your crew, or yourself. besides studies have shown driving hot does not save much time over all. (I know the longer the trip the more time saved).

 

[zzyzx]

That may be true. Does not matter what the man died from. The issue is the driver changing shifts in the middle of an emergent transport.

Oh BTW, I have never seen that in an American system, in 20 years!

That happened in Minneapolis/St. Paul a year or two ago. It was discussed on this site. Sorry, but I couldn't find the link.

 

[downunderwunda]

Calm down Crocodile Dundee.

Before we go any further, I have shown you enough respect to not refer to you as a moronic 20 year old movie character who never has & never will have any relevance to EMS. I have quoted here for you the relevant community rules regarding this.

we will not tolerate rudeness, defamatory or insulting posts,

don't ever say 4 minutes is negligible. Ever.

Is this based on the same mentality that still believes the golden hour is real? Firstly, if this is a 'Heart Attack', which one can only assume is Myocardial Ischaemia, then lets be realistic. I would put money on the fact the patient has had some discomfort for well over 60 minutes BEFORE they called you. is another 4 gonna matter?????????? So I arrive, I take their Obs, administer ASA, Nitro get a line started, more nitro, some morphine load & go. I have dilated the vascular bead, thus releaving the ischaemic attack that has been there for 60 mins prior. I transport to hospital, they thrombolyse if indicated, arrange an ICU bed & the patient is managed until a cath lab is available. I have seen pts wait up to 3 months for stenting (which is under review i believe). So what relevance does your 4 minutes have now?

If is was a CVA, then hmmm, again, i bet they didnt call at the immediate point of symptom onset, so again, the time frame is, while critical, not set in stone. If it is haemhorragic, their mortality rate is significantly over 90%, ischaemic, under 30%. Locality of haemhorrage is irrelevant (

Based on the size and location of the CVA it can make a big difference.

) when a patient is coning it is because there is no room in the cranial space. then their mortality is predicted.

If that's the way you treat your patients I feel sorry for them.

You base this on what? An opinion I have offered in a forum that is cortrary to yours? Mine is based on scientific evidence based practice. Yours is based on what? I have many letters of thanks from patients & their families for the assistance I have offered them, for the honesty I have shown them. I will never lie to a patient or their family, but rather tell it how it is. For that they are greatful. I have to live in a small community where, as a paid professional I am expected to know what I am doing.

Wouldn't you want your patient to have the best possible outcome and quality of life?

Of course I do, but do i want to shove my head in my *** & think I can save everybody as well? EMS needs to offer patients, families & friends realistic outcomes, nor pipe dreams that will never be realised.

I'm not making a judgment on those medics because as you say, I don't have all the facts. But I find hard to believe that any excuse can warrant the actions these particular medics took. Who knows, maybe I'll be surprised but I doubt it.

You have made judgment when you said

What could possibly be this man's reason for clocking out during a transport? Maybe if just found out his wife/son/daughter was dying and that moment and he needed to be with them would warrant leaving the pt , but even then its unethical.

That is a judgment you have made, without all the facts, without their side of the story.

And its thrombolysis, not thrombolyasis. If you are going to be smug about using proper medical terms, be sure they are indeed the proper medical term.

My apologies for having fat fingers, if you take a moment to look at your keyboard, you will notice the A is beside the S, my fat fingers are truly sorry. However, you have missed the point of why i pointed out the fact I used correct terms. I will spell it out for you as you have missed it. I am a medical professional. This is a forum for people involved with EMS & if we want to be taken seriously, treated professionally, then we should start by using the correct terms when we communicate with each other. If you find this too difficult, then we can still use terms that you understand like Heart Attack, Stroke & fit instead of CVA, AMI & Seizure.

 

[Bloom-IUEMT]

Before we go any further, I have shown you enough respect to not refer to you as a moronic 20 year old movie character who never has & never will have any relevance to EMS. I have quoted here for you the relevant community rules regarding this.



Well I don't know about you but I'm a huge fan of Crocodile Dundee and it wasn't meant to be mean...more like cheeky and playful!

If is was a CVA, then hmmm, again, i bet they didnt call at the immediate point of symptom onset, so again, the time frame is, while critical, not set in stone. If it is haemhorragic, their mortality rate is significantly over 90%, ischaemic, under 30%. Locality of haemhorrage is irrelevant ( ) when a patient is coning it is because there is no room in the cranial space. then their mortality is predicted.








You base this on what? An opinion I have offered in a forum that is cortrary to yours? Mine is based on scientific evidence based practice. Yours is based on what? I have many letters of thanks from patients & their families for the assistance I have offered them, for the honesty I have shown them. I will never lie to a patient or their family, but rather tell it how it is. For that they are greatful. I have to live in a small community where, as a paid professional I am expected to know what I am doing.




Of course I do, but do i want to shove my head in my *** & think I can save everybody as well? EMS needs to offer patients, families & friends realistic outcomes, nor pipe dreams that will never be realised.



You have made judgment when you said



That is a judgment you have made, without all the facts, without their side of the story.



My apologies for having fat fingers, if you take a moment to look at your keyboard, you will notice the A is beside the S, my fat fingers are truly sorry. However, you have missed the point of why i pointed out the fact I used correct terms. I will spell it out for you as you have missed it. I am a medical professional. This is a forum for people involved with EMS & if we want to be taken seriously, treated professionally, then we should start by using the correct terms when we communicate with each other. If you find this too difficult, then we can still use terms that you understand like Heart Attack, Stroke & fit instead of CVA, AMI & Seizure.

God, I will repeat myself: I am not passing judgment on these poor poor blokes I am simply relaying my doubt as to what kind of situation necessitates leaving a CVA or AMI pt while you take a detour to clock out
That is bad patient care no matter how much you want to rationalize it. Albeit, it worse to clock out to go the movies than it is to visit a dying loved one, but that still doesn't excuse the bad patient care. ANd maybe for some reason they did need to clock out at that particular moment...i dont know....Im not saying for sure because I dont know the entire story. You absolutely right in saying there is two sides to every story.....a man who chops up his family has HIS side of the story to tell as well. Doesn't mean it excuses the facts.

That is fine you made a mistake typing, and I agree medical terms should be used in place of lay-terms, but there is no reason to be so insolent about your use of them as if you are so elevated in patient care and professionalism that we mere amateurs most defer to your infinite medical knowledge :wacko:

If you want to be so professional and use professional terms, proofread and correct spellings errors. It seems antithetical to profess wanting to be taken as professional yet misspell , either by purpose or mistake, the medical terms you advocate use of.

Look, did the four minutes make a difference between his life or death? I don't know. I do know that with a pt having a CVA or AMI time is tissue. Maybe I am misunderstanding what you are saying but it seems that you are thinking in black and white, live or dead. My friend there is a whole gray area between the two which is deemed "quality of life." Your job, my job, our job is to not just get the patient there alive.....its to do what we can to ensure they're best possible post-acute-condition recovery. "Golden Hour" b.s. aside, the quicker a patient gets to the hospital with a serious acute condition, the better the outcome. It may not mean the difference between life of death but it may put the patient in better quality of life...and that is why I got into medicine. I'm not just here to save lives, I'm here to improve lives.

I'm not real good with CNS arterial anatomy so I'll try to illustrate my point best I can-----an artery in right superior parietal lobe anterior to the primary sensory and motor cortex gets occluded and patient presents with some loss of memory and numbness in left face and left arm. Transport immediately and you better get those thrombolytics in the pt before they lose motor function because the motor cortex is just posterior to sensory cortex (I might have it backwards though^_^ ) The point being a few minutes might be the difference between persistent numbness or having to go through physical therapy.
Another aspect you are missing is that a pt might not just have one clot. A minor CVA may be a precursor to a larger CVA. TIA's are often seem before the onset of large CVAs. ANd you as EMS don't know that the next clot might occlude the carotid!!
So irrespective of the said EMS personnel's motive behind detouring to clock out of their shift, it looks bad the patient died. In reality you are right in saying the 4 min. detour probably didn't matter medically. But in the eyes of family it does, in the eyes of the public it does. Its just poor reasoning and not the dumbest EMT in our service would do that because in the eyes in of the public, its not professional and its not ethical.

 

[Bloom-IUEMT]

Another source of story

http://www.timesonline.co.uk/tol/life_and_style/health/article6452448.ece

Seems driver complained about working overtime and pt was critical.

 

[djmedic913]

Is this based on the same mentality that still believes the golden hour is real? Firstly, if this is a 'Heart Attack', which one can only assume is Myocardial Ischaemia, then lets be realistic. I would put money on the fact the patient has had some discomfort for well over 60 minutes BEFORE they called you. is another 4 gonna matter?????????? So I arrive, I take their Obs, administer ASA, Nitro get a line started, more nitro, some morphine load & go. I have dilated the vascular bead, thus releaving the ischaemic attack that has been there for 60 mins prior. I transport to hospital, they thrombolyse if indicated, arrange an ICU bed & the patient is managed until a cath lab is available. I have seen pts wait up to 3 months for stenting (which is under review i believe). So what relevance does your 4 minutes have now?

So, we have established that ischemia will happen before infarction. So you give O2, ASA, Nitro, and Morphine. So you have temporarily delayed the inevitable infarct. I believe we are in agreement here. So with proper medicine and MD management, this may have a chance of surviving with mininal damage to the heart.

BUT if your treatment was withheld for another 4 minutes, depending where the ischemia is, your patient may have coded waiting for you another 4 minutes...


As for the golden hour: It still exists but is not always possible.

 

[downunderwunda]

As for the golden hour: It still exists but is not always possible.

Do you do all of your pre hospital medical assessments based on marketing principals?

Unfortunatley we cannot teach common sense. Medic Mills will never be able to teach when to stay & play & when to load & go, it comes with experience.

BUT if your treatment was withheld for another 4 minutes, depending where the ischemia is, your patient may have coded waiting for you another 4 minutes...

Woulda, Shoulda, Coulda. We have to work on what was put in front of us at the time. Instead of saying

if your treatment was withheld for another 4 minutes

try If the patient had called 4 minutes earlier, same outcome.

AMI patients need ICU, we can only delay until we arrive, althoug with the use of pre-hospital thrombolysis, this is improving outcomes continually.

 

[downunderwunda]

but there is no reason to be so insolent

& calling me Crocodile Dundee isnt?

Look, did the four minutes make a difference between his life or death? I don't know. I do know that with a pt having a CVA or AMI time is tissue. Maybe I am misunderstanding what you are saying but it seems that you are thinking in black and white, live or dead. My friend there is a whole gray area between the two which is deemed "quality of life." Your job, my job, our job is to not just get the patient there alive.....its to do what we can to ensure they're best possible post-acute-condition recovery. "Golden Hour" b.s. aside, the quicker a patient gets to the hospital with a serious acute condition, the better the outcome. It may not mean the difference between life of death but it may put the patient in better quality of life...and that is why I got into medicine. I'm not just here to save lives, I'm here to improve lives.

I never said it was Black or White, I said we need to be realistic. Do you know the difference between a Haemhooragic CVA & an Ischaemic CVA? I can only presume you are talking Ischaemic CVA because they have excellent recovery rates & the amount of defecit is dependant on eary diagnosis thrombolysis, & properly managed rehabilitation. I would suggest you take a good look at Haemhorragic CVA & then comment the same way. Mortality & Morbidity, even in an ICU is still over 90%. Regarless of time, defecit is nearly alway irreversable & quality of live is minute.

I'm not real good with CNS arterial anatomy so I'll try to illustrate my point best I can-----an artery in right superior parietal lobe anterior to the primary sensory and motor cortex gets occluded and patient presents with some loss of memory and numbness in left face and left arm. Transport immediately and you better get those thrombolytics in the pt before they lose motor function because the motor cortex is just posterior to sensory cortex (I might have it backwards though ) The point being a few minutes might be the difference between persistent numbness or having to go through physical therapy.

I would suggest you re read what I said. I never suggested delaying more than necesarry, but how many CVA patients will arrive at hospital, & lie on a Hospital bed in an ER for 25, 30 mins waiting for a CT? Where does the 4 minutes fit now?

Another aspect you are missing is that a pt might not just have one clot. A minor CVA may be a precursor to a larger CVA. TIA's are often seem before the onset of large CVAs. ANd you as EMS don't know that the next clot might occlude the carotid!!

Ah, hello, I do know the difference between a CVA & a TIA. There is only 1 diagnostic tool to tell the difference. 24 hours. Now where is your 4 minutes?

So irrespective of the said EMS personnel's motive behind detouring to clock out of their shift, it looks bad the patient died. In reality you are right in saying the 4 min. detour probably didn't matter medically. But in the eyes of family it does, in the eyes of the public it does. Its just poor reasoning and not the dumbest EMT in our service would do that because in the eyes in of the public, its not professional and its not ethical.

In reading the further link you posted, he should no longer be employed.

However, as one comment said

To those using this story to bash the NHS - this is a story precisely because it is unusual. It's NOT the norm. You have NO idea of the envy with which people across the world regard the NHS, and you will.be.sorry if the private sector get their claws on the British health industry.

Yes it looks bad. There is no 2 ways about it. He has done wrong. The whole point was to show that un until then, too many people had been Judge, Jury & EZxecutioner without being in full possesion of the facts.

No EMS system in the world is perfect, this highlights the problem. People do not understand the nature of time in EMS being non existant. However, at least the NHS recognise the value of the work undertaken by their Ambulance Service & pay their employees, not relying on volunteers.

 

[Scott33]

at least the NHS recognise the value of the work undertaken by their Ambulance Service & pay their employees, not relying on volunteers.

Whereas I will agree that the NHS have a better system in general, EMS in the UK is no longer a one-man show. The NHS simply could not operate at the scale of which they do, if it were not for volunteers. Specifically CFRs (AKA ORCON clock stoppers), and SJA who have been known to assist with cat C calls in some regions, as well as their event stuff.

Not to mention the many trusts who now have little choice but to contract out some of the lower end IFT jobs, due to demand outweighing supply.

No system is perfect, and no system is free of the odd irresponsible provider who will come along every so often, and make headline news-worthy errors in their practice.

Stupidity knows no geographical boundaries.

 

[reaper]

&

I would suggest you re read what I said. I never suggested delaying more than necesarry, but how many CVA patients will arrive at hospital, & lie on a Hospital bed in an ER for 25, 30 mins waiting for a CT? Where does the 4 minutes fit now?



.

Do your hospitals really make them wait 30 minutes for a CT?

 

[ffemt8978]

Do your hospitals really make them wait 30 minutes for a CT?

Sometimes...that's how long it takes to call the Radiology crew in from home. Granted, since our transport times are an hour it's not an issue for us, but some agencies can be at the hospital in less time than it takes for them to call the necessary people in.

 

[Scott33]

Do your hospitals really make them wait 30 minutes for a CT?

It does seem a little much. 5 mins or so is the norm in my place if they are showing obvious signs. I have even seen them taken straight from the ambulance stretcher onto CT table. CVA core measures (for those places in which it applies) would not be met with a 30 minute or more wait, so it is as much a reimbursement issue in the US, as it is a practical one. Reimbursement not an issue in other countries.