Absolutely appalled

[mississippimedic]

I am new here and this topic may not be the best choice for me to comment on as I am sure that I may make a bad first impression. I use A caps and the arm drift. I not saying that I will never have a negative outcome but I have not yet. I will also tell people that I believe are faking seizures to hold that arm still so I can start the IV. Sure is funny watching people seize all over for except their arm that I'm starting the IV in.

 

[Veneficus]

Without passion or prejudice.

I am not condoning “torturing” patients. Nor am I holier than any other healthcare provider. But today a colleague and I were discussing an article he read about medical students on Medscape. I didn’t read it myself, but he relayed to me that most medical students lose their compassion for patients around the 3-4th year of school. (Which in the US is the start of their clinical)

So with his background in psych and mine in anthropology, we figured we would discuss why. We came to the conclusion that it has to do with being the subject of abuse. Similar to a child in an abusive family, there is the stress placed on the student from preceptors, hospital staff, patients, and oneself. (Sometimes in the guise of “paying your dues.”)

Eventually people will respond to provocation, it is simply a matter of reaching the threshold.

I have seen the same in all types of providers. I have even reached the threshold on occasion myself. Just like the difference between palliative pharmacological therapy and euthanasia, the line in the sand is intent. There is a difference between performing medical treatments that are indicated without compassion or taking the most medically expedient path to reach the diagnostic or treatment goals and torture.

It takes a lot out of people (especially in high volume areas both EMS and in hospital) to constantly give of themselves. On any given day being called names, having a full urinal thrown at you, and any number of forms of abuse by patients only adds to the drain a provider feels. Long hours and little recognition or high demands can also cause a person to reach their threshold sooner. Compassion gives way to medical necessity, and as we all know, medicine can be downright scary to behold, especially without compassion. I don’t think providing needed medical treatment can be deemed “torture” even if there are “nicer” ways of doing things. There is a difference between lack of compassion and malice.

I have even seen resource management dictate care.

I once saw a combative teenage psych patient brought to the ED by her mother. (A lawyer no less) She was so frustrated by her daughter she announced to the staff. "I'll sign any paper you want, do whatever you have to." It makes me think if a mother could reach such a point with her own child, any given healthcare provider could reach such a point of frustration and lack of empathy or compassion with a patient.

Humiliating a patient and providing unjustifiable procedures most likely would qualify as inappropriate. But there may also be a justifiable interventions performed while being sarcastic or cold. It is always interesting to me to see an outsider’s or new provider’s perspective of medicine.

A quick perspective on IV starts and sizes. Does a larger needle provoke more nociceptive pain than a smaller one? Would it not be dependent on the quantity of regional pain receptors? Does a larger bore or length needle have more of a psychological response than a painful one? Is it dependant on conditioning? To put it to the test, when I go to the hospital today I will take the “Pepsi challenge.” I’ll have a classmate start an IV with an 18G and then with a 14G without knowing which is which. While N=1 is not a large sample, it may provide some insight without having to get permission from an ethics board for a pain test.

 

[Seaglass]

I don't like punitive medicine. Sure, it bothers me when a patient's faking it, but I'm not the type to start hurting them. Although I do get a lot of satisfaction from the ones who will hold an arm still when asked while "seizing," or the guy who responds to reports of "pt is supposedly unresponsive, but here's what I see" by waking up and yelling "I'm not faking!"

I have a few coworkers who get pretty nasty with any and all 'unresponsive' patients. Even their first 'trap pinches' will leave a large bruise. If I'm on with them, I'll usually try to be the one assessing responsiveness, for obvious reasons. Doesn't always work.

The worst I've heard yet is one partner's account of when he got a spousal abuser. (And yes, PD was involved, etc.) After seeing the victim, who was transported by another crew, my partner decided he'd do all kinds of stuff... giant IVs, eyebrow tape, "responsiveness tests," and so on. Apparently the receiving hospital turned a blind eye. I wasn't there, so I don't know what really happened, but it wouldn't surprise me if it's a true story.

To put it to the test, when I go to the hospital today I will take the “Pepsi challenge.” I’ll have a classmate start an IV with an 18G and then with a 14G without knowing which is which. While N=1 is not a large sample, it may provide some insight without having to get permission from an ethics board for a pain test.

I'm very curious to see how this will go.

Personally, I've noticed that needle size doesn't matter, but repetition does. The first stick doesn't hurt much, but it becomes progressively worse for me if repeated. Repeated shots also hurt a lot worse than repeated sticks, and what's in the shot makes a difference. But I have some medical history that generally makes my nociception a little screwy, so I'm kinda doubtful about whether I'm a representative case.

 

[CAOX3]

double post

 

[CAOX3]

The worst I've heard yet is one partner's account of when he got a spousal abuser. (And yes, PD was involved, etc.) After seeing the victim, who was transported by another crew, my partner decided he'd do all kinds of stuff... giant IVs, eyebrow tape, "responsiveness tests," and so on. Apparently the receiving hospital turned a blind eye. I wasn't there, so I don't know what really happened, but it wouldn't surprise me if it's a true story.

If this is true.

No place for this in EMS. We are not judge and jury, this provider should be shown the door.

 

[ExpatMedic0]

you haven't even finished what is required of you to be a Paramedic in OR yet which I also find appalling that a state which lays claim to requiring a 2 year degree when it actually doesn't. You are young and once you injure a few patients because you fail to understand what it is that you are doing, hopefully you can return to your EMT-B status permanently. Doing something "just because" or "that is how it has always been done" just shows how far you still have to go with your education. If you can not understand why something like the arm drop is harmful, I seriously wouldn't want you around medications especially narcan. This thread has probably given you way too many ideas of how you can abuse or torture the patients you don't like.

First off everyone on this forum who has stated they use the hand drift test (including paramedics of 20+ years) all have reported no problems with it. Are you saying your better or smarter than them? The hand drift is not appalling or out dated its a matter of opinion.
With all do respect you are not always right and you need to get it over it. I hate to flatter you or encourage you at all and I am sure it will backfire on me, But I do find a lot of what you say on this forum interesting and informative in many ways. You seem like a very intelligent person and probably a good medic when it comes to patient care. But if your bedside manner and way that you interact with your EMS coworkers is anything at all like on this forum, I feel for them.


2nd off I was an EMT for almost 6 years and a paramedic for 2, its does not matter what states I am licensed/certified in as Paramedic I hold certification in multiple states. Just because I am going back to college to complete a degree to better myself and my career does not make me new to EMS.

But whats "appalling" to me is your personal attacks, always trying to get the last word in, and extreme stubborn attitude. What you think of my states EMS system, and me has nothing to do with our topic.
YOU need to respect other people's opinions and you are not an M.D. you work under one, just like the rest of us. It quite apparent to me why you have been banned from this forum in this past.

with all that said Ill let you have the last word on this.... It would be a waste of time to argue with you and just end up getting this topic locked for all the others who are using it.

 

[VentMedic]

First off everyone on this forum who has stated they use the hand drift test (including paramedics of 20+ years) all have reported no problems with it.

Everyone? Go back and read the posts again. You just don't want to listen to reason and you seem to not have enough A&P to understand what damage the arm drop test will do.

You are assuming all the patients you drop their arm across their face will be conscious and pull back. Thus, you are injuring the patients who need your help the most.

Again, if your instructors did not give you the complications and consequences for the procedures they taught you, they have failed you. I seriously hope they do better with the medication section.

When you are abusive to a patient or can cause them harm, do not expect me to respect you in any way or to condone your behavior. I would rather advocate for your license to be removed so the rest of the EMS providers (or the patients) do not have to suffer a black eye for your actions.

 

[46Young]

I much prefer to twist the skin on the inside of the upper arm to test responsiveness rather than the arm drift or sternal rub, if more gentle maneuvers prove unsuccessful. No one would expect that, and it can be quite painful if applied with enough force. This is to be used as a genuine last resort to test for a painful response, not as punitive Tx.

I've witnessed some abhorrent behavior during my EMS travels, I'm suprised no one has mentioned these yet:

Drunk tossing - set up the cot at a pre determined distance, one EMT grabs the pt's arms, the other grabs the legs, and 1,2,3, heave ho!

Piggybacking lasix on the pt, to make them urinate on themselves while extended in triage. Good systems either use a pyxis, or other methods of med accountability to prevent illicit use, either on the pt or themselves. Thank goodness for that. I've seen some get fired for swiping benadryl, lasix, and high dose epi among others for personal use. How many knuckleheads have you witnessed bragging about starting a line on themselves, running in a liter or two, some D50 O2 and thiamine to relieve a hangover?

One crew bragged about carrying around extra 18G's to practice getting sticks on drunks' fingers. Whether they needed a line or not.

Securing someone well to a LSB, and then driving at high speed down a bumpy, pot hole strewn city street (Jamaica Ave in the mid to upper 100's) to cause pain, fear, and discomfort for the "allstate-itis" pt.

How about purposefully letting your pt get soaked in a rainstorm (when it was preventable) because they called for "BS" at 0300?

Anyone who withholds pain meds from a pt when indicated, due to the inconvenience of documentation, restock, QA/QI review and such.

 

[Seaglass]

Newbie question: is the hand drift test the same as the hand drop? I know the hand drift test as part of stroke assessment, where you have the pt close their eyes and raise their arms... I'm not aware of that being noxious...

Drunk tossing - set up the cot at a pre determined distance, one EMT grabs the pt's arms, the other grabs the legs, and 1,2,3, heave ho!

Piggybacking lasix on the pt, to make them urinate on themselves while extended in triage. Good systems either use a pyxis, or other methods of med accountability to prevent illicit use, either on the pt or themselves. Thank goodness for that. I've seen some get fired for swiping benadryl, lasix, and high dose epi among others for personal use. How many knuckleheads have you witnessed bragging about starting a line on themselves, running in a liter or two, some D50 O2 and thiamine to relieve a hangover?

One crew bragged about carrying around extra 18G's to practice getting sticks on drunks' fingers. Whether they needed a line or not.

Securing someone well to a LSB, and then driving at high speed down a bumpy, pot hole strewn city street (Jamaica Ave in the mid to upper 100's) to cause pain, fear, and discomfort for the "allstate-itis" pt.

How about purposefully letting your pt get soaked in a rainstorm (when it was preventable) because they called for "BS" at 0300?

Anyone who withholds pain meds from a pt when indicated, due to the inconvenience of documentation, restock, QA/QI review and such.

Sheesh. I thought some folks at my department were bad. But I've never heard anyone brag about most on that checklist. Only the self-medication for hangover (which I've never actually seen), and the withholding of pain meds (which is usually done out of the misguided idea that it's in the patient's best interest).

If this is true.

No place for this in EMS. We are not judge and jury, this provider should be shown the door.

If it's true. Like I said, I wasn't there, and I'm not his supervisor or in any position at all to pass judgment. Can't imagine it would be an easy call if I were, either. He's not one of the usual jerks. I've run with him on some calls that were pretty frustrating, and I've never once seen him employ punitive measures. The armchair shrink in me has suspected before that he told me that story because he regrets it.

 

[46Young]

Newbie question: is the hand drift test the same as the hand drop? I know the hand drift test as part of stroke assessment, where you have the pt close their eyes and raise their arms... I'm not aware of that being noxious...



Sheesh. I thought some folks at my department were bad. But I've never heard anyone brag about most on that checklist. Only the self-medication for hangover (which I've never actually seen), and the withholding of pain meds (which is usually done out of the misguided idea that it's in the patient's best interest).



If it's true. Like I said, I wasn't there, and I'm not his supervisor or in any position at all to pass judgment. Can't imagine it would be an easy call if I were, either. He's not one of the usual jerks. I've run with him on some calls that were pretty frustrating, and I've never once seen him employ punitive measures. The armchair shrink in me has suspected before that he told me that story because he regrets it.

That's NYC for ya. Plenty of mutants out in the field along with the professional providers.

 

[EMSLaw]

How many knuckleheads have you witnessed bragging about starting a line on themselves, running in a liter or two, some D50 O2 and thiamine to relieve a hangover?

In the hierarchy of idiocy discussed in this thread, sucking down some high-flow O2 post hangover probably doesn't even make a blip on the screen. One of the upsides of being a basic is that your partners can't do anything too stupid to themselves.

 

[WolfmanHarris]

So wait, if I'm following this correctly the "arm drop" is not only practised by some providers here, but has been taught in class? That suggests one of two scenarios, that published textbooks are teaching this (dubious), or instructors with no more education then their students and years of experience built on deficient theory are passing on bad if not potentially injuring habits on as standard. I find the second one more likely. I already see this when I teach Lifeguards and FR's when past instructors have taken their way of doing things and made it the standard.

Allowing your frustration with patients to be taken out on them in any physically or mentally abusive way is a slippery slope. So today you're putting leads on a drunk's head, maybe tomorrow you decide to smack one upside the head yourself. You're supposed to be the one who brings calm to the situation. Sure I transport a-holes and idiots same as everyone else: but the most change you'll see in me is a less sunny demeanor and a firm, no-nonsense tone. My job pays me very well and I enjoy it. I'm not going to throw it away by letting my emotions control me. But more importantly, I'm a professional.

And if you (the proverbial "you") can't act like a professional, than please, get out of my profession.

 

[VentMedic]

That suggests one of two scenarios, that published textbooks are teaching this (dubious), or instructors with no more education then their students and years of experience built on deficient theory are passing on bad if not potentially injuring habits on as standard. I find the second one more likely. I already see this when I teach Lifeguards and FR's when past instructors have taken their way of doing things and made it the standard.

I just checked a couple of textbooks including Brady and found these listed as appropriate painful stimuli to test for responsiveness:

sternal rub
pressure to arch above the eye
pressure to the fingernail bed
pinching the earlobe or shoulder skin
squeezing the muscle as the base of the neck

There was no mention of arm drop and as I remember it when I was first heard about doing this many years ago, it was a "trick of the trade" and not something that was ever put in print or "acceptable" for documentation. However, you may have to admit to it if you do damage or lie and include the injuries as part of your "found with" assessment.

 

[Veneficus]

n=2

I'm very curious to see how this will go.

Personally, I've noticed that needle size doesn't matter, but repetition does. The first stick doesn't hurt much, but it becomes progressively worse for me if repeated. Repeated shots also hurt a lot worse than repeated sticks, and what's in the shot makes a difference. But I have some medical history that generally makes my nociception a little screwy, so I'm kinda doubtful about whether I'm a representative case.

So today I carried out my "study" on the subjective pain levels between insertion of a 14g and an 18g IV catheter. My partner in crime (he didn't consent to be called "lovely assistant") even volunteered himself to increase the sample size 100%. (same morbid curiosity too)

I guess I should disclaim up front that this is a highly biased experiment with a very small sample size and is more meant to satisfy my curiosity, not to determine best practice. The subjects participating are probably certifiably insane, know enough to be imminently dangerous to the lives and health of others, have really good insurance, and unlimited access to professionals who impart their twisted ways on us and find it just as entertaining. In short, we are "experts." (scary thought) Do not try this at home.

I do not have veins in my hands that would accommodate a 14g catheter. So I had to offer up my median cubital veins.

I could feel the difference between the insertion of the 14 vs. the 18. I would not say it really caused more distress as the pain difference was rather minimal.

As my friend is not as initiated to the medical world, he was more apprehensive to start. He also stated he was considerably worried about how much the 14 would hurt having just seen and inserted one for the first time. (looks like a sword doesn’t it?) Anyway he was tense and offered that he expected it to hurt more than it did. He also mentioned that had he not seen the needle prior, he probably would not have known there was a difference between the sizes and the 14 insertion was just the level of pain to expect when somebody was inserting a piece of stainless steel of any size into his body.

There you have it, pseudoscience at its finest. B)

Now if only I can find one of those implanted contraceptive needles. (I swear it must be an 8 guage at least)

Maybe I could get a spot on "myth busters" and get paid to play around.

 

[firetender]

Vene, my Brother, you miss the point (pun intended), though you did one fine job of getting the point, but you did so for no damn good reason: Size Doesn't Matter!

The Medic who thinks they are instilling more pain by the size of the needle is not really serious about inflicting damage to their patient. The ones who are dangerous are the ones who brandish the 12 gauges in delight; using threat as torture and then making sure they follow through...slowly! Unfortunately, there are such people in the back of ambulances.

I do NOT condone such things; just a reflection of what I've seen.

 

[Veneficus]

Vene, my Brother, you miss the point (pun intended), though you did one fine job of getting the point, but you did so for no damn good reason: Size Doesn't Matter!.

That's just something they tell the little guys

Really though, I always wondered if there was more of a psychological impact of being stabbed with a needle than actual physical pain. (I don't routinely get stabbed or cut to know) In that respect, I think we discovered that there is significant psychological impact. Even if our method was flawed.

Sometimes time passes slowly, and the time can be made more interesting with stuff like that I guess.

Besides, nephrology clinicals are dreadfully boring usually. Sometimes something goes horribly wrong for somebody and the game is on. (Like last week) but usually it is an excercise in staying awake or not losing your vision reading lab values.

The Medic who thinks they are instilling more pain by the size of the needle is not really serious about inflicting damage to their patient. The ones who are dangerous are the ones who brandish the 12 gauges in delight; using threat as torture and then making sure they follow through...slowly! Unfortunately, there are such people in the back of ambulances.

I do NOT condone such things; just a reflection of what I've seen.

Being soley planted in Myers-Briggs ENFJ category, I agree, if you must resort to physical torture, you are not very good at it.

Nobody would give me a 12g or 10g outside of theatre I do so like procedures.

 

[Seaglass]

I just checked a couple of textbooks including Brady and found these listed as appropriate painful stimuli to test for responsiveness:

sternal rub
pressure to arch above the eye
pressure to the fingernail bed
pinching the earlobe or shoulder skin
squeezing the muscle as the base of the neck

There was no mention of arm drop and as I remember it when I was first heard about doing this many years ago, it was a "trick of the trade" and not something that was ever put in print or "acceptable" for documentation. However, you may have to admit to it if you do damage or lie and include the injuries as part of your "found with" assessment.

If someone writes it up in a PCR, I'd take it as a sign that they really don't know better.

I first learned about the arm drop as a test for conversion disorder or catatonia. It is used clinically, but rarely (both of those are rare to start with), and for actual diagnostic purposes, as opposed to determining who's faking and who's not.

 

[mississippimedic]

Yeah it's scary sometimes what people don't know what to document or more importantly, what in the world they are doing. I know of a guy that pushed 90mg of dopamine and then documented it.

 

[reaper]

If he pushed 90mg of Dopamine, I would sure hope he documented it! Anything else is fraud and lying.

 

[mississippimedic]

you are correct, it would be fraud and lying, I was using that as an example to the previous post.


If someone writes it up in a PCR, I'd take it as a sign that they really don't know better