Anyone ever been denied an intubation during clinicals?

[CANMAN]

[/QUOTE] While the Charge Nurse was drawing up the Succs I leaned over and asked "Are you all seriously going to RSI this lady?" to which he replied "Yep! This is why you never throw a fit in an ER!"[/QUOTE]

With your above comment I agree with others here in that your delivery is the issue.... You are a PARAMEDIC STUDENT and the way you have stated that you addressed the staff makes it seem like you are a "know it all" and questioning them. They, unlike yourself, have already finished education and achieved certification, licensure, etc. You my friend have not.

With that being said they may have been performing a procedure that you do not agree with or understand but I tend to think its not your place to question, in a trauma bay, while the procedure is about to take place, their judgement. Others may disagree with me here but this is my opinion. They may have keyed in on other assessment clues etc that you did not pick up on and based on their assessment/knowledge the procedure may have been warrented.

I think a more appropriate way to address with situation would be to pull the RN aside post-procedure and ask a question such as: "why did you guys decide to RSI this patient" and see what they say, you just may learn something. Also with the intubation issue, like USAF said it happens but if you can't professionally address the issue it will continue to happen to you. Next time you are at clinical make contact with the MD's working, inform them you are a paramedic student here for the day, how far you are in your program, what your looking to acheive for the day/learn and ask them if they would be willing to include you on any procedures or assessments they feel you would benefit from. I can 100% assure you better luck with this method, and before you get defensive re-read my entire post and realize I am trying to help you.... :beerchug:

 

[Smash]

Of course this is also why I think EMS student need to be shadowing physicians in the ED and not nurses.

Amen to that! We were lucky, we stuck with one (sometimes 2) anaesthesiologists, or attendings or whatever depending on where we were. We had very little to do with nurses which is entirely appropriate in my view.
That continues out in the real world too. I don't hand over sick patients to nurses, I hand over to Doctors and will wait for one to be present until I give my report. Unless of course they are well patients, but for sick ones it's the doctors I speak with.

 

[281mustang]

While the Charge Nurse was drawing up the Succs I leaned over and asked "Are you all seriously going to RSI this lady?" to which he replied "Yep! This is why you never throw a fit in an ER!"

With your above comment I agree with others here in that your delivery is the issue.... You are a PARAMEDIC STUDENT and the way you have stated that you addressed the staff makes it seem like you are a "know it all" and questioning them. They, unlike yourself, have already finished education and achieved certification, licensure, etc. You my friend have not.

With that being said they may have been performing a procedure that you do not agree with or understand but I tend to think its not your place to question, in a trauma bay, while the procedure is about to take place, their judgement. Others may disagree with me here but this is my opinion. They may have keyed in on other assessment clues etc that you did not pick up on and based on their assessment/knowledge the procedure may have been warrented.

The context of my question was asked more in an inquisitive mannor and lacked any real form of a "know it all" demeanor. I can see what you would imply from just reading the quote but that's not at all how it was asked of (I believe) interpreted.

I think a more appropriate way to address with situation would be to pull the RN aside post-procedure and ask a question such as: "why did you guys decide to RSI this patient" and see what they say, you just may learn something.

While we were in the CT control room I did ask another Nurse why she was RSI'd and was told it was common practice for this specific MD when they're screaming and won't calm down. She then went on about expaining how readily the other Physicians in the ER intubate and what each requires from their patient's condition before they're willing to tube them.

Also with the intubation issue, like USAF said it happens but if you can't professionally address the issue it will continue to happen to you. Next time you are at clinical make contact with the MD's working, inform them you are a paramedic student here for the day, how far you are in your program, what your looking to acheive for the day/learn and ask them if they would be willing to include you on any procedures or assessments they feel you would benefit from. I can 100% assure you better luck with this method, and before you get defensive re-read my entire post and realize I am trying to help you.... :beerchug:

I understand that, I'm not offended and appreciate the points you brought up.:beerchug:

 

[bstone]

...but that's the problem. If a student from another ambulance walked up to you and identified them as a paramedic student and asked to have access to your drug box, would you just hand over the drug box? If a student's first interaction with an individual physician is, "Hi, I'm a student, can I intubate?" then I find it reasonable to decline the student to intubate that specific patient.


Of course this is also why I think EMS student need to be shadowing physicians in the ED and not nurses.

I don't know about where you went to school but at the ER where I did my Intermediate training I had an official hospital polo shirt and an official hospital picture ID that identified me as an EMT-Intermediate Student. That way there was no confusion as to who or what I was.

 

[JPINFV]

For EMT clinicals, white dress shirt, black slacks, and a little name tag.

 

[RocketMedic]

Making the decision to RSI a combative patient with no medical need to intubate sounds a lot like a malpractice suit waiting to happen. Im not opposed to chemical sedation, but a full om RSI is not in the patients best interest. Sounds like that MD needs to get a stern talking to.

 

[STXmedic]

I had an MD that was going to do that last night before I explained the patient to him. Apparently the nurse taking report considered uncooperative and combative the same thing...

 

[usafmedic45]

Making the decision to RSI a combative patient with no medical need to intubate sounds a lot like a malpractice suit waiting to happen.

Only if something goes wrong and then only if someone on the staff rats the doc out. Most people value their jobs too much to do something like that. Besides, if nothing untoward happened to the patient and full RSI was used at least at a theoretical level there would be no demonstrable harm to the patient which is a necessary requirement for a malpractice lawsuit to be successful.

Sounds like that MD needs to get a stern talking to.

Of course, but that's assuming that what the OP is telling us is actually correct. We are getting one side of the story here and admittedly from someone who got told 'no' to a request. Let's not crucify the doc without some credible evidence to support the OP's claim. For all we know, the patient had more going on than he was aware of and the doc was just being sarcastic in the comment allegedly made to the OP about "throwing a fit".

 

[firetender]

During my clinical time I never asked a doctor to do a procedure but I asked if I coukd observe a few times. Luckily our docs would ask me if I wanted to do procedures. I found being there asking them questions when it was appropriate and interacting with them that they became comfirtable and would include me in everything possible including tubes, meds pushes, cardiac and cva and codes.

This is all about taking the time and exercising the patience to form relationships with staff in the hospital. Not just the Docs but the RN's as well, who, once they're sure you're not a loose cannon, will vouch for you.

If you're serious about stepping in and getting hands-on experience then it serves you well to be available to assist at any level so that when the right time comes you are a known entity who is not a threat.

In a nutshell; Get Known!

 

[the_negro_puppy]

I guess if the Doc didnt know you should would be hesitant to let you step up to the plate.

Then again, I bet if that same Doctor's mother was very sick or injured and needed intubation, she would hope/like a paramedic with experience intubating to drop the ETT.

 

[RocketMedic]

Only if something goes wrong and then only if someone on the staff rats the doc out. Most people value their jobs too much to do something like that. Besides, if nothing untoward happened to the patient and full RSI was used at least at a theoretical level there would be no demonstrable harm to the patient which is a necessary requirement for a malpractice lawsuit to be successful.



Of course, but that's assuming that what the OP is telling us is actually correct. We are getting one side of the story here and admittedly from someone who got told 'no' to a request. Let's not crucify the doc without some credible evidence to support the OP's claim. For all we know, the patient had more going on than he was aware of and the doc was just being sarcastic in the comment allegedly made to the OP about "throwing a fit".

I'm in total agreement with you on the story- we don't have both sides, nor do we have the information. That being said, it is not appropriate for anyone, even a doctor, to be dropping/RSIing patients simply due to their behavior. If there's an actual problem, then it could be appropriate, but the thought of a self-important MD working an ER RSIing her misbehaving patients based solely on their behavior does scare me somewhat.

I'm not saying that it wasn't done technically correctly, but even with experienced providers, there's always room for error. Taking that risk for no reason is no bueno.

 

[Smash]

I'm in total agreement with you on the story- we don't have both sides, nor do we have the information. That being said, it is not appropriate for anyone, even a doctor, to be dropping/RSIing patients simply due to their behavior. If there's an actual problem, then it could be appropriate, but the thought of a self-important MD working an ER RSIing her misbehaving patients based solely on their behavior does scare me somewhat.

I'm not saying that it wasn't done technically correctly, but even with experienced providers, there's always room for error. Taking that risk for no reason is no bueno.

Notwithstanding the Doctor's aside to the nurse, which may have been tongue in cheek - we don't really have any context - we really have no idea what the thought process was. Where is the line between "combative" because they are a drunken a-hole, and "combative" because they have run their car into someone else and have a closed head injury? Perhaps this patient warranted a CT and the Doctor may have decided that unconscious was the best way to achieve that without putting the patient and staff at risk when she went to the Doughnut of Death.

 

[281mustang]

Only if something goes wrong and then only if someone on the staff rats the doc out. Most people value their jobs too much to do something like that. Besides, if nothing untoward happened to the patient and full RSI was used at least at a theoretical level there would be no demonstrable harm to the patient which is a necessary requirement for a malpractice lawsuit to be successful.



Of course, but that's assuming that what the OP is telling us is actually correct. We are getting one side of the story here and admittedly from someone who got told 'no' to a request. Let's not crucify the doc without some credible evidence to support the OP's claim. For all we know, the patient had more going on than he was aware of and the doc was just being sarcastic in the comment allegedly made to the OP about "throwing a fit".

My reasoning for questioning the Nurse about RSI was to see if there was something that I was unaware of as I came in towards the latter part of the transfer and had nothing to go off other than her vitals and meds she was believed to be on.

The Charge Nurse was the one that made the comment about the pt getting tubed because 'she was throwing a fit'. I know his personality/sense of humor pretty well and can gauge pretty well when he's being facetious. If you think I fabricated their comments to spite the doctor I really don't know what to tell you.

I didn't create this thread to flame an ER doc, I created it to see how prevelent these situations are.

 

[bstone]

While riding my bike home from school this evening I was thinking about the EMT-Doc pairing in the ER. I very much agree. We are working under the doc's license and under the doc's direction.

 

[281mustang]

While riding my bike home from school this evening I was thinking about the EMT-Doc pairing in the ER. I very much agree. We are working under the doc's license and under the doc's direction.

Yep. Nurses are great, but they just don't have the "lets review the pt's S/S to attempt to diagnose this and see what treatment is required" approach to the situation that we need.

 

[Smash]

My reasoning for questioning the Nurse about RSI was to see if there was something that I was unaware of as I came in towards the latter part of the transfer and had nothing to go off other than her vitals and meds she was believed to be on.

The Charge Nurse was the one that made the comment about the pt getting tubed because 'she was throwing a fit'. I know his personality/sense of humor pretty well and can gauge pretty well when he's being facetious. If you think I fabricated their comments to spite the doctor I really don't know what to tell you.

I didn't create this thread to flame an ER doc, I created it to see how prevelent these situations are.

I don't think usafmedic was trying to imply that you were fabricating anything, but obviously what you tell us is filtered through what you perceive, and in your above statement (coming in late etc) you demonstrate why this is an important point to consider. What you as a medic student perceive may not be what I, usaf, the nurse, the doctor or someone else may perceive. This is not intended as a slight on you, or to put down your intelligence or ability, it is merely the way the world is.

 

[281mustang]

I don't think usafmedic was trying to imply that you were fabricating anything, but obviously what you tell us is filtered through what you perceive, and in your above statement (coming in late etc) you demonstrate why this is an important point to consider. What you as a medic student perceive may not be what I, usaf, the nurse, the doctor or someone else may perceive. This is not intended as a slight on you, or to put down your intelligence or ability, it is merely the way the world is.

I'm not deneying the Physician obviously had a better idea of the pt's condition than myself.

I had a hunch that everything wasn't on the up and up which was confirmed by two other Nurses. Is it possible neither had a full grasp of the situation and just assumed the worst? Absolutely. Just sharing what happend from what I saw on my side of the fence.

 

[usalsfyre]

RSI'ing a combative patient who needs a CT scan to r/o head injury is entirely appropriate. It was very common practice at several trauma centers I've been around. A patient must be still to get a quality image. My wife who is a rad tech reports it's much safer for the patient and the staff for the patient to be intubated and vented than chemically snowed to the point they will lay still enough for a CT without a secure airway.

 

[RocketMedic]

RSI'ing a combative patient who needs a CT scan to r/o head injury is entirely appropriate. It was very common practice at several trauma centers I've been around. A patient must be still to get a quality image. My wife who is a rad tech reports it's much safer for the patient and the staff for the patient to be intubated and vented than chemically snowed to the point they will lay still enough for a CT without a secure airway.

Once again, agreed, but this is assuming we have a closed head injury. From the op, thats a possibility. That buys a tube if true.
If, on the other hand, that doc is dropping people for being emotional, misbehavior, etc...no bueno.

Remember that physicians are not always right, or even on the right track, and neither are nurses or paramedics. If you see something off, ask. If you know somethings off, tell them about it repectfully. If that doc is a good one, theyll listen to you and cooperate. If theyre not, you might get reamed. If you get reamed, well, you know who not to see yourself.

Medicine isnt a cert contest.

 

[usalsfyre]

I agree, but the OP described an ETOH female post head-on MVC presenting as combative. I saw nothing inappropriate there, rather I saw an OP that didn't understand the risk associated with not performing the procedure.

I've gone toe-to-toe with physicians and nurses over crappy medicine on more than one occasion. Agreed we can't knock people out over emotions or bad behavior...to a point. If they present a danger to themselves or others to the point the amount of chemical sedation required endangers their airway, they still buy a tube.

If anything I've seen far less inappropriate intubations by physicians than paramedics.