Paramedic Incompetence Question

[systemet]

Position found in indicated head trauma. We'll move past the moi.

While I've been told by medical directors past that if I bring in an intoxicated patient with altered LOC and photogenic head trauma, and there's a c-spine issue, they'll hang me out to dry -- I'm not sure that the location the patient is found in gives us the MOI here.

Did anyone reliable witness the traumatic event? Did he just roll out of bed (if so / no c-spine needed), or did he get beat up by four guys in a parking lot after doing a bunch of coke, crawl home and pass out on the floor? Are we able to distinguish these two events based on the information present?

Because if he's just rolled out of bed, the c-spine isn't indicated. But if you're planning on doing a 1,000 calls / year for the next 20-30 years, you want to be pretty sure when you're making decisions that you're going to be held accountable for.

Spinal exam is unobtainable due the pt's mental status.

Well, strictly speaking, the physical examination is still present, it's just limited by the ability of the patient to describe their neurological function. Likewise the history is compromised by the patients LOC, but might be provided by bystanders.

It seems like this is going around in circles. Here's some quick opinions:

* Clinical practice guidelines may vary by location, by country, county / state / province, and even by city, or ambulance service.

* The overwhelming majority of patients receiving c-spine precautions in North America do not have unstable c-spine fractures, nor are they at risk for unstable c-spine fractures.

* C-spine precautions are routinely overapplied in situations where they're not clinical indicated with detriment to the patients involved.

* While NEXUS and Canadian C-spine Rule attempt to provide evidence-based criteria for rule out in conscious, sober, alert, adults with minor mechanisms, there are no evidence based guidlines for situations like the one you describe.

* This is a grey area. Protocols are written on the assumption that the world is black-and-white. It's not. This is why the provider should be sufficiently educated and experienced to apply them as guidelines.

* A lot of systems and a lot of medical directors would rather just avoid the ethical and legal consequences of someone poorly trained, or having a bad day, applying judgment inappropriately, so they accept a small degree of harm to a large number of patients to avoid a large degree of harm to a small number of patients. This in itself should define why this situation is a grey area.

 

[Veneficus]

May I?

So, I guess what I'm getting at is would you not board a patient unless they had unequal pupils? Had unilateral weakness? Complained of back pain? Only one of these things is obtainable in unconscious patients. I'm in EMS because I want to be able to take a good history, so I'm uncomfortable when the patient can't talk. When I'm uncomfortable, I tend to take precautions. Sure, that's my training, but it's also my intuition as a human being. But, by all means, please enlighten me. Where do you draw the line?

I would like to point out to you there is a difference between head injury and spinal injury.

While brain injury and spinal injury can exist concurrently, it is not automatic.

It may benefit you to review the signs and symptoms of two.

There is a myriad of neuological exams and findings in an unconscious patient. Like Babinski or deep tendon reflexes.

If you patient was actively resisting you, which I understand that to be the case at least at some point from your original description, even more neuro findings are possible if you know what you are looking for and how.

If you became a Basic EMT to be good at history and physical, you wasted your time. Unless you went to some extreme basic class, I am willing to bet you probably know much less than you think about it.

A history and physical starts with paleopathology and epidemiology. If you nothing about either, you are already at a disadvantage.

Books detailing a complete history and physical exam are almost as many pages as your EMT text and written at a far higher level than 8th grade. If you tried to highlight the important parts, you might as well use a paintbrush the important details are so densely presented.

The truth comes out.

You are uncomfortable with patients. That is not a sin. Everyone starts that way. But patient condition is not dictated by provider comfort.

I suspect you may never have seen a patient that requires the full efforts of multiple highly capable providers to manage. That is not a sin either, as many in EMS do not see these patients regularly or regularly enough to be comfortable.

But it is important to understand where you stand.

The first act of taking care of patients you are uncomfortable with is calling somebody with more knowledge and/or experience.

That was done. So the next step is to learn.

There is a cost to medicine in the US. It is not free and it is rarely forgiven. If you start performing unindicated procedures or tests because of your lack of comfort you can cause the patient unneeded harm.

Performing every test and treatment "just in case" is the mark of a hobbyist who is guessing and really has no idea.

Aka, worse than no help at all.

Going with your gut instead of your head.

Because let's call a spade a spade, you have intuition but barely demonstrated any knowledge so far.

Do you think it would negatively affect a patient if your "gut" told you the patient's chest pain was caused by an MI and you treated it when in fact it was a ruptured aneurysm because you didn't have enough knowledge in your head to tell between the two?

Would the emotion to do "something" overcome the rationale that you may be in over your head and err on the side of doing nothing in order to not make matters worse?

(don't answer here, just think about it.)

 

[Veneficus]

Just use some clinical judgement and don't blindly follow protocol...technically your pt (with GCS 9) is a category B trauma patient per my state's protocol, and you should request a medivac helicopter to transport your patient to the nearest Level 1 trauma center, with no need to consult beforehand with the trauma center and obtain permission. Don't be that guy.

You must e from MD, where the revenue generated by outrageous airmedical use supercedes patient benefit by any justifyable measure.

If anyone reading this ever called a helicopyter for this, I hope the patient sends the multithousand dollar bill right to your agency or you directly if you are a volunteer. With a note from their lawyer thanking you.

The very reason you don't need to call med control is so there is no responsibility conveyed to a Dr. for such a decision.

 

[AMF]

There is a myriad of neuological exams and findings in an unconscious patient. Like Babinski or deep tendon reflexes.

If you patient was actively resisting you, which I understand that to be the case at least at some point from your original description, even more neuro findings are possible if you know what you are looking for and how.

If you became a Basic EMT to be good at history and physical, you wasted your time. Unless you went to some extreme basic class, I am willing to bet you probably know much less than you think about it.

A history and physical starts with paleopathology and epidemiology. If you nothing about either, you are already at a disadvantage.

That myriad of neurological exams is what I was talking about. Not in my scope, so I can't write it in a run report or anything, but good to know nonetheless.

Who do you think I'm at a disadvantage compared to? Myself if I wasn't EMT-B? I think that's doubtful. I think I've made it pretty clear that I don't think I'm an expert. As for head injury vs spinal injury, while I can appreciate the the difference to some degree, so can the board of medical directors who put head injury as an indication for spinal immobilization.

Overtreating is a big issue, particularly in our specialty, but I don't really think that's the concern here. The point that several have brought up that really bothers me is that boarding a patient could do more harm than good. Other than that, I absolutely agree with everything you're saying.

 

[JPINFV]

That myriad of neurological exams is what I was talking about. Not in my scope, so I can't write it in a run report or anything, but good to know nonetheless.

A physical exam is outside of your scope of practice? Does your scope of practice limit what signs you can look for during a physical exam? What's the point of continuing education if you can't implement it?

 

[rescue1]

You must e from MD, where the revenue generated by outrageous airmedical use supercedes patient benefit by any justifyable measure.

If anyone reading this ever called a helicopyter for this, I hope the patient sends the multithousand dollar bill right to your agency or you directly if you are a volunteer. With a note from their lawyer thanking you.

The very reason you don't need to call med control is so there is no responsibility conveyed to a Dr. for such a decision.

How did you guess? <_<

I once had a paramedic state emphatically that an emotional disorder patient involved in an extremely minor accident (25 mph into a curb) was category B trauma due to her altered mental status...luckily saner heads prevailed and the helicopter was canceled.

Though to be fair, I believe if the State Police fly you in Maryland, you fly for free.

 

[medic417]

How did you guess? <_<

I once had a paramedic state emphatically that an emotional disorder patient involved in an extremely minor accident (25 mph into a curb) was category B trauma due to her altered mental status...luckily saner heads prevailed and the helicopter was canceled.

Though to be fair, I believe if the State Police fly you in Maryland, you fly for free.

Maybe free to patient but costs tax payers a ton.

 

[rescue1]

Yeah true. I don't mind a tax based system...but in Maryland you can fly people who stub their toe if you feel the urge (and some people will try).
That being said, my local (small town) hospital won't accept most trauma, and I'm at least an hour from any trauma center. If I take someone by ground, ALS will be with us, meaning I'm taking away half of the county's ALS coverage (only 2 ALS cars in the county) for at least two hours, if not three. It's unfortunate that the situation exists, but sometimes for us, the helicopter is the best option simply because it prevents areas of the county from being left without coverage.

 

[Veneficus]

Though to be fair, I believe if the State Police fly you in Maryland, you fly for free.

But you still get a bill where you land.

There is a shortage of both trauma and critical care surgeons, so those bills are never going to be cheap.

 

[Veneficus]

A physical exam is outside of your scope of practice? Does your scope of practice limit what signs you can look for during a physical exam? What's the point of continuing education if you can't implement it?

To be fair to AMF, yes, his/her physical exam is limited.

But probably not as drastic as was stated.

An EMT-B better not be doing any sort of Gyn exam in the field other than checking for crowning or bleeding.

Digital rectal and rectoscopy is also right out. (as they say on monty python)

However, short of that, I cannot think of one State or any place I have ever heard of that limits neuro exams, non invasive physical exam, heart sounds, opthalmoscopy, otoscopy, rectal temperature, or any other form inspection, auscultation, palpation, or percussion not specifically excluded above.

The only caution I would offer is if you don't know how to do it, you probably shouldn't document what you think you find, or keep it real vague, like " potentially adnomal heart tones that may require further investigation."

 

[AMF]

To be fair to AMF, yes, his/her physical exam is limited.

But probably not as drastic as was stated.

An EMT-B better not be doing any sort of Gyn exam in the field other than checking for crowning or bleeding.

Digital rectal and rectoscopy is also right out. (as they say on monty python)

However, short of that, I cannot think of one State or any place I have ever heard of that limits neuro exams, non invasive physical exam, heart sounds, opthalmoscopy, otoscopy, rectal temperature, or any other form inspection, auscultation, palpation, or percussion not specifically excluded above.

The only caution I would offer is if you don't know how to do it, you probably shouldn't document what you think you find, or keep it real vague, like " potentially adnomal heart tones that may require further investigation."

By don't know, do you mean not properly/officially trained? I've never heard of an EMT CME class covering physicals (although I haven't taken PHTLS yet, and I suspect they might do something like that)

 

[JPINFV]

Any CME class that covers any disease process is also going to cover signs and symptoms of the disease. Besides, there's always the concept of life long learning. You don't need an instructor to pick up a book like Bates and integrate what you learn into your practice of prehospital medicine.

Edit: I also know of a case where a paramedic caught a dystonic reaction from what he learned from a scenario on an EMS forum. He did contact medical control to confirm the diagnosis and treatment, but without incorporating what he learned he would have never called medical control in the first place.

http://www.emtcity.com/index.php/topic/14938-emtcity-helped-me-make-the-diagnosis/

 

[Veneficus]

Who do you think I'm at a disadvantage compared to?

I think you are at a disadvantage to somebody who actually knows what they are doing.

I think that that is a major disservice to a patient.

I am not saying you are responsible for the failure of US EMS training.

But I think this case points out a very harsh reality.

EMS training is based around injuries and illnesses that are very high severity.

However, these patients are a minority of the ones that are seen and the curriculum, while it has had basic science emphasized, it is still woefully inadequete when it comes to determining sick/not sick.

When over treatment costs increase, it devaluates the people providing it. Anyone can over treat, but it takes skill to be accurate, which is economically efficent.

But what it means to the provider in the field is:

You're not getting a raise.

...and who couldn't use a raise?

What it means to all of the "pre-med" or those aspiring to other healthcare professions is that your time and efforts in EMS will not be appreciated in your respective future.

When you work hard and sacrifice and it doesn't pay out later, that just sucks. It is a wate of time and money.

 

[AMF]

What it means to all of the "pre-med" or those aspiring to other healthcare professions is that your time and efforts in EMS will not be appreciated in your respective future.

When you work hard and sacrifice and it doesn't pay out later, that just sucks. It is a wate of time and money.

Well, that's just, like, your opinion, man.

In all seriousness, I've certainly come to appreciate being an EMT. If you mean adcoms won't appreciate it, I'll admit that many pre-health students have certifications in EMS or pharm, but it definitely hurts not to have it. Or so I'm told.

 

[JPINFV]

In all seriousness, I've certainly come to appreciate being an EMT. If you mean adcoms won't appreciate it, I'll admit that many pre-health students have certifications in EMS or pharm, but it definitely hurts not to have it. Or so I'm told.

It definitely doesn't hurt to not have an EMS certification, especially since there are plenty of experiences equal to or superior to EMS experience. What can hurt, though, is overvaluing EMT training and certification, especially for the pre-meds who have the certification but never use it.

 

[Veneficus]

Well, that's just, like, your opinion, man.

In all seriousness, I've certainly come to appreciate being an EMT. If you mean adcoms won't appreciate it, I'll admit that many pre-health students have certifications in EMS or pharm, but it definitely hurts not to have it. Or so I'm told.

:rofl:

The poor creatures, they don't know any better...

 

[rhan101277]

Performing every test and treatment "just in case" is the mark of a hobbyist who is guessing and really has no idea.

While this statement has some merit, sometimes people themselves aren't sure what is wrong with them and a little more digging needs to be done. They give a poor chief complaint like, "I feel sick", "I just don't feel right", "I am in a fog" etc.

It is also a "fools errand" to get tunnel vision and not think of all the differentials that could be the cause.

 

[Veneficus]

While this statement has some merit, sometimes people themselves aren't sure what is wrong with them and a little more digging needs to be done. They give a poor chief complaint like, "I feel sick", "I just don't feel right", "I am in a fog" etc.

That is a normal day at the office, especially in geriatrics who seem to only have a handful of symptoms that manifest similarly in every possible disease.

It is also a "fools errand" to get tunnel vision and not think of all the differentials that could be the cause.

There is a big difference between casting a wide net to make sure you leave nothing out and throwing everything at somebody hoping something sticks.

 

[firetender]

There is a big difference between casting a wide net to make sure you leave nothing out and throwing everything at somebody hoping something sticks.

Don't forget, Vene, you are speaking from a place of having been exposed to the ins and outs and ramifications and sub- and advanced levels of diagnosis backed by a thorough study of disease entities.

Here, you're dealing with people who aspire to gain just a small piece of your knowledge while essentially working in a (non-self imposed) tunnel.

"throwing everything at somebody hoping something sticks" often becomes part of EVERYONE'S learning curve that helps them understand using the proper limits of a net.

 

[JPINFV]

Something else to think about. The maximum shotgun approach possible in the average EMS system is often going to amount to a basic initial assessment for a physician. It's not like the average paramedic is going to be able to shotgun lab tests outside of a BGL or order a CT, or any similar imaging test.