"Is he competent?". Do you have protocols or informal standards?

[chaz90]

Maybe it's just me, but in 14 years, I have never ever seen a paramedic give chemical restraints for an EDP on a 911 call. and I have never see a paramedic or a nurse give a chemical restraint to a psych person during a transport.

The west coast might be different, but I have never even heard of it being done on the east coast

Little bit of an aside here, so I apologize. I certainly use both Haldol and Versed as chemical restraints. Haven't done it a ton yet out in DE, but (knock on wood), I haven't had too many combative patients out here either. In Colorado, I saw sedation used somewhat frequently in both Fort Collins and Commerce City. It's really a disservice to the patient, the hospital staff, PD, and EMS to fail to appropriately manage combative patients with pharmacological interventions when it becomes necessary. Even with short transport times, waiting for the hospital to do it for you means more time fighting on scene and during transport with a greater chance for the patient to hurt himself or a provider and greater exposure of the hospital staff to unnecessary risk upon arrival. How much time does it really take to draw up a syringe and give an IM injection anyway?

 

[Handsome Robb]

The thread started with the question as to whether EMS or ambulance service had actual protocols. SO far I am not actually seeing anything like that.



There is a principle that something is so apparent that the reasonable person does not need a specific warning or instruction, but in a world where we get coffee cups warning us it is hot, and reading about EMTs putting backboards on standing people, I thought someone's service would have something in protocol form:



S/S and complaint=>measures to take=>expected outcome and its indicators.



Is the bigger question this: do you have ready access to your protocols? Are they reasonable and understandable? Are they over three inches thick? :unsure:

I gotcha now.

Yes, we have a standard but there is always the caveat of paramedic discretion. I'll try to find it tomorrow for you.

I have my protocols on my phone and they automatically update through the Paramedic Protocol Provider app. It is also very easy to access them on our employee portal. They're ~160 pages including the "drug definitions" section which is about 55 pages.

 

[Bullets]

saying no? we can't do that.... people want a taxi ride, and we don't require payment. plus they will get seen quicker if they come in by ambulance. plus if we don't transport, we can't bill, and we need all the revenue we can get because we don't get any tax funds.

BTW, I've done all those things except for the last one.

Guess thats just a facet of the different models...as a municipal third service, we are funded though the municipal budget, so we dont need the billables to survive.

Weve also developed a pretty good relationship with the local ER, so we will pull up to the public entrance and drop "patients" in the waiting room.

Our service basically told the cops very early on that we are busy enough without doing crisis transports, if they request us to a crisis and the patient is walking around uninjured, we WILL leave and make the cops transport. Psych calls accounted for 1.6% of our calls in 2013

 

[RescueRider724]

It really depends on the jurisdiction you are operating in. I was a LEO for 8 years and in our SOP's (UCMJ, local PM standing orders) if there was a combative PT that needed transport we were required to transport them to the ER, unless they required continuing medical care en route, then we were required to ride the bus with the medics. You might be surprised how many civilian (non-military or dependant) people we ran in to on base both here and OCONUS. We were the detaining authority and therefore the PT was our responsibility until handed off to medical (meaning a hospital or similar facility pre designated by command) or jailing authority.

Working on the rescue, there have been a few situations where the officers were not able to leave the scene immediately (chain of custody concerns), and I have been asked by the medics to ride along to assist if needed.

 

[mycrofft]

It really depends on the jurisdiction you are operating in. I was a LEO for 8 years and in our SOP's (UCMJ, local PM standing orders) if there was a combative PT that needed transport we were required to transport them to the ER, unless they required continuing medical care en route, then we were required to ride the bus with the medics. You might be surprised how many civilian (non-military or dependant) people we ran in to on base both here and OCONUS. We were the detaining authority and therefore the PT was our responsibility until handed off to medical (meaning a hospital or similar facility pre designated by command) or jailing authority.

Working on the rescue, there have been a few situations where the officers were not able to leave the scene immediately (chain of custody concerns), and I have been asked by the medics to ride along to assist if needed.

How did you clear arrestees medically for incarceration?
EDIT: add: the propensity for illness or drug overdose etc to mimic just being a jerk or drunk led to deaths which led to medical screenings before jails accept arrestees. Had a guy who was arrested standing in the street with a handgun; turns out he was hyperthyroid AND had pheochromocytoma (what are the odds).

 

[mycrofft]

Little bit of an aside here, so I apologize. I certainly use both Haldol and Versed as chemical restraints. Haven't done it a ton yet out in DE, but (knock on wood), I haven't had too many combative patients out here either. In Colorado, I saw sedation used somewhat frequently in both Fort Collins and Commerce City. It's really a disservice to the patient, the hospital staff, PD, and EMS to fail to appropriately manage combative patients with pharmacological interventions when it becomes necessary. Even with short transport times, waiting for the hospital to do it for you means more time fighting on scene and during transport with a greater chance for the patient to hurt himself or a provider and greater exposure of the hospital staff to unnecessary risk upon arrival. How much time does it really take to draw up a syringe and give an IM injection anyway?

Not wanting to give chem restraint where appropriate is like not wanting to see a taser or prostraint chair used when appropriate. Squeamishness which ends up in someone getting hurt or injured or killed.

 

[Handsome Robb]

How did you clear arrestees medically for incarceration?

EDIT: add: the propensity for illness or drug overdose etc to mimic just being a jerk or drunk led to deaths which led to medical screenings before jails accept arrestees. Had a guy who was arrested standing in the street with a handgun; turns out he was hyperthyroid AND had pheochromocytoma (what are the odds).

We have a very specific protocol for medically clearing someone to go to the jail.

No subjective complaint, no serious objective findings (this one can bite you in the butt, they might take some facial lacs but others they'll kick back because they want them evaluated for sutures or something ridiculous like that, even if it obviously does not), A&Ox3 and able to ambulate with minimal assistance.

Then on top of that the patient cannot want to go to the hospital and there is very specific vital sign parameters.

SBP 90-180 mmHg
DBP <110 mmHg
SpO2% >89 %
FSBG 60-400 mg/dL
HR 50-120 BPM
BAC <0.40

You laugh about he BAC but we have multiple people here who are walking, talking coherently and fully capable of carrying for themselves that sit in the .4-.55 range. Sometimes the jail will take them but usually not due to a concern about DTs/seizures and other withdrawal symptoms.

 

[RescueRider724]

How did you clear arrestees medically for incarceration?
EDIT: add: the propensity for illness or drug overdose etc to mimic just being a jerk or drunk led to deaths which led to medical screenings before jails accept arrestees. Had a guy who was arrested standing in the street with a handgun; turns out he was hyperthyroid AND had pheochromocytoma (what are the odds).

We did not, docs had to clear them if we had any inclination they might have a medical or psychological issue. Could be a pain in the rear on a busy Friday night, but I never heard of any medical issues once they were in the military or civilian jails.

 

[mycrofft]

Robb: quote: " the patient cannot want to go to the hospital "

I fully understand where that comes from, but if an arrestee says "Man, I need to go to the ER" and it turns out he's right, all hell might rain down AND the pt could suffer.

So prehospital EMS clears arrestees for incarceratrion? So many places in that for trouble unless the jail also does a screening. We didn't use to re-screen arrestees returning from an ER trip to get booked until we got a few sent back as "fit for incarceration" (per the ED) when in fact they were still FUBAR because the ER was "too busy", or did the arresting officer a favor, or the pt was acting out. I'm talking intracranial bleeds, botched suturing attempts, already in active DT's, in active labor, etc.

On the blood alcohols (and after about 1990 virtually all were actually urine tests) we'd take them with a high alcohol but they would be expedited to the detox section (my neck of the woods for six years) where we'd do Q4hr VS and started the protocol when they started detoxing. But no one accepted in active acute detox.

 

[Handsome Robb]

Robb: quote: " the patient cannot want to go to the hospital "

I fully understand where that comes from, but if an arrestee says "Man, I need to go to the ER" and it turns out he's right, all hell might rain down AND the pt could suffer.

So prehospital EMS clears arrestees for incarceratrion? So many places in that for trouble unless the jail also does a screening. We didn't use to re-screen arrestees returning from an ER trip to get booked until we got a few sent back as "fit for incarceration" (per the ED) when in fact they were still FUBAR because the ER was "too busy", or did the arresting officer a favor, or the pt was acting out. I'm talking intracranial bleeds, botched suturing attempts, already in active DT's, in active labor, etc.

If the patient wants to go to the hospital and there is a valid reason I'm going to take them no questions asked. With that said you of all people should know how often that one gets used. I agree though it is a situation that is very high risk. We always, well I always err on the side of caution. Hard takedown and your head bounced off the pavement if I don't take you the police are going to. See what I'm getting at?

Most of the arrests we clear are intox related or after a hard takedown, I see cops walking patients into the ED all the time too though. It's not uncommon for them to need to go to the ED prior to being incarcerated but they refuse us and the cops will take them provided it's not something beyond very low acuity.

 

[mycrofft]

If the patient wants to go to the hospital and there is a valid reason I'm going to take them no questions asked. With that said you of all people should know how often that one gets used. I agree though it is a situation that is very high risk. We always, well I always err on the side of caution. Hard takedown and your head bounced off the pavement if I don't take you the police are going to. See what I'm getting at?

Most of the arrests we clear are intox related or after a hard takedown, I see cops walking patients into the ED all the time too though. It's not uncommon for them to need to go to the ED prior to being incarcerated but they refuse us and the cops will take them provided it's not something beyond very low acuity.

Sounds sound.
I had a state prison transport driver try to palm off a hallucinating psychotic once for an overnight transport stop. I thought he was talking to someone behind him in line, but I looked up and he WAS the last in line.The officer is not always your friend, especially near end of watch.

 

[Handsome Robb]

Sounds sound.

I had a state prison transport driver try to palm off a hallucinating psychotic once for an overnight transport stop. I thought he was talking to someone behind him in line, but I looked up and he WAS the last in line.The officer is not always your friend, especially near end of watch.

Bolded the important part. This is nothing against our brothers in blue but I've had plenty of cops try to take advantage of me and force a patient on me or me on a patient. Not going to fly dude.

When they say hospital or jail I always say, "you can only go to the hospital if you have a legit ament complaint it's not a get out of jail free card and it's going to cost you a couple thousand dollars." They usually pick jail.

Some of the cops here hate me.

 

[mycrofft]

Taking an arrestee or inmate to a medical facility they know they are going to can lead to an ambush. Happened to us once. But I digress.

 

[Handsome Robb]

It's not uncommon for our ERs, particularly the TC to get locked down and have officers posted at every entrance. Basically any violent crime that seems like there may be retaliation/follow-up, high level prisoners, things like that. Really freaking obnoxious sometimes. I've had them try and hold me at the door with an arrest, not gonna happen bud, I promise you my patient isn't going to jump up and go after the guy and we won't either.