Dr. House... AKA medical resident JPINFV. I am going to address the points you made. You undoubtedly will have another off the wall rebuttal, and I will undoubtedly defend my passionate views. In the spirit of keeping the general topic as opposed to the specificity of this particular issue, I beg your leave.
You and I will clearly not agree, and we clearly come from different systems and have different outlooks on life in general, given your exuberant compassion and dare to dream that a homeless regular may one day be suffering a tragic frontal lobe tumor or that it may not be his chronic alcoholism which I have witnessed for years after extending a helping hand and watching him waste away due to his inability to make decent choices and exert personal responsibility. No, I should assume he is altered not because of the empty Steel Reserve/Bud Ice/211 tall cans next to him. I should assume his sodium levels are dangerously low, or perhaps he is having a CVA/TIA... I mean... After all, his speech is slurred and his gait unsteady. Maybe a it's an acute anticholinergic syndrome, I mean it is hot as hell out side, but this guy is certainly blind as a bat, red as a beet, hot as a hare, dry as a bone, dang it he's as mad as a hatter... Tachy too... Dysrhythmia alert?!?! Better do a 12 lead too!
While you may take that approach, your position may allow you to. Unfortunately.... I say again.... UNFORTUNATELY, that just is not the way it works in most urban centers. I have worked EMS in 3, each one similar in essence. If I came at everyone like they were dying not only would I look like a fool, but I would crash my career into smithereens faster than a speeding bullet.
You must look at the whole picture... The whole picture. Is it easy to dismiss that guy? Certainly is. Perhaps he should have not have cried wolf 365 times last year, and more of us would take his precarious situation more seriously. That's the system I work in. I can encounter a drunk in the morning, haul him in to the ER where he can sleep it off. And then low and behold get called out again to the same guy, behind the convenience store drunk as a skunk again in the afternoon, and haul him back. (They all have Medicaid too, but I'll get to that later.) "Psych" patients too.
That said, before you accuse me of lacking compassion and caring for those I am supposed to help.... I can do a thorough assessment on everyone if I deemed it appropriate. I can also use my common sense and critical thinking skills to guide me. And one more thing before you say one day someone is going to die due to my cavalier attitude; everything I do while on the clock for my patients, is in their best interests. Do what is in you patients best interests at the time, and you'll never go wrong, and never question your morals.
Educating the public is also part of my job. Therefore, I don't see a problem with advising someone of alternatives to transport in my emergency service vehicle. The mantra that "you called 911 so it must be an emergency" is out dated.
Early on while posting I said..... This is the way my system works. This is what I think would better EMS, in my area. If you want to play Doctor House then... Go ahead. We're all going to be laughing at you behind your back.
Is it too much to train EMS to do this? Heck, being able to deescalate is useful for non-psych patients who may be uppity.
No, it is not too much to train us better. We have "a lot of holes" in our education as you put already though, so....
Also be sure you incorporate some self defense training and maybe an arm bar or take down techniques.
Point being: police are better suited to handle that. In a manner least likely to cause undue injury to themselves or to the patient.
Which is safer... chemical restraints or physical restraints?
Physical. By far. The way it has for centuries. Why risk getting a dirty needle stick or infecting a patient by breaking the skin when you don't need to. For that matter why inject a medication into a person who is so out of wack that they can't tell you if they are allergic to it. What if they go into anaphylaxis?
Point being: less invasive to most invasive. Is it prudent at times? Absolutely, and it is for those "true" psych emergencies.
...and it's relatively stupid that EMS can't make a medico-legal decision. (side note: In California, physicians can write the same hold and individuals designated by the county health department can also write holds... i.e. RNs on psychiatric evaluation teams).
Irrelevant. Those folks aren't responding lights and sirens to everyone who is feeling sad or depressed today. Perhaps they should.. ::lightbulb:: Excellent suggestion Dr! Why, that might get us to meet in the middle and satisfy us both.
...yet all of them are going to be evaluated by a psychiatrist...
Not true. Some, a "mental health tech" or simply an ER doctor who will assess as I have and likely come to the same conclusions. Maybe run a test, for liability's sake. Don't worry, it won't cost the patient a thing.
So your system's dispatch protocols suck. That doesn't change the fact that it's a medical problem, not a law enforcement problem.
Already addressed. I'm taking about a growing subvert of patients... That are not EMS requiring patients either. They need policing, not a babysitter or a free meal.
Et. Al. As I've been saying includes the cited examples and other similar manner of nonsense.
By "this person" do you mean acute psych breaks or people playing the system?
If I use the term person instead of the term patient in this discussion in this context, I am referring to a person who is not a patient or should not be a patient in the traditional sense.
What does your opinion "as a tax payer" have to do with this? Do you think that emergency medical care should be provided based off of insurance or presumed value?
My opinion as a tax payer is relevant. And you are using the term "emergency" very loosely again. While I agree that care should not be refused based on ability to pay... EMTALA... And that's my limit. Stabilizing care. Therefore, if already stable... Sorry.
Where I disagree is this for example, a call I had the other day. Called out for a Delta Chest Pain/SOB. AOS to a residential neighborhood on a clear warm day. Two females are standing outside in the roadway in front of the address I was dispatched to chatting it up with the 4 firefighters in front of the engine. There is an SUV parked a few feet in front of it. We pull up along the curb in front of the SUV. As I get out an walk towards the scene one of the females approaches, "That's my cousin over there, she needs the help." Initially I had seen that these two are in no apparent distress, without grimace or guarding, ambulatory without difficulty, appearing to be under no duress with ABC's intact. The first female says "I'm going to follow you to the emergency room." I acknowledge and continue to the "patient." Fire says all V/S stable WNL, c/o abd pain, we're out of here, and have a good day fellas. I instruct the patient to walk with me; she does so without difficulty and without appearing in pain/distress.{everything between the stars can be skipped unless you want to see exactly how I arrived at my conclusion that this person is not having a true emergency and is a waste of time, resources, money, and oxygen}
********As I assess and gather history this patient tells me she has had ongoing (chronic) GI issues for about 3 years including Chrohns, UTIs, cholecystectomy, appendectomy, uterine fibroids. Some of which she has been seen for in the Emergency Room more than 10+ times since the beginning of this year. She states she is "tired of those doctors not knowing whats wrong with me." Her most recent issue has been a bout of Giardia. She was seen in the emergency room 6 days ago, diagnosed, and prescribed a 5 day Z pack (antibiotics.) Today is the 4th day of her regiment, her cramping has not subsided, and therefore she would like to go to the ER. Pain is as it has been the last time: cramping in the lower quadrants, 10/10 (clearly, as she is texting her friends and fidgeting through her purse on the way in) non radiating, increasing on exertion or palp. She is physically unremarkable. Abd is soft/nondistended, bowel sounds normal (yes I actually listened.) No difficulty with voiding and bowels PRN. Diahrrea of course as you'd expect with Giardia. No other complaints whatsoever including pertinent negatives that I'm not listing. Diet: soda and fried foods/fast food, and some social ETOH recently. ******
The patient requests to go to a hospital that is pretty far away, about half way across town. Noting also that we would be passing 4 other closer ERs, the closest about a mile away. She is adamant about it, even as I suggest the closer hospitals. We can't refuse, so okay... I also ask "why can't your cousin take you." Her reply, "oh I'm going to the emergency room; I need the ambulance." I tell her there is a fair chance she is going to have to wait in the lobby regardless, and that I can't do little more for her other than sit next to her on the way in. She replies, "that's fine, but I need the ambulance, I have insurance." I ask for her ID & insurance card. She proceeds to hand me her out of state drivers license and her State of Nevada Medicaid card. (We're in Nevada) and her cousin followed closely, all the way to the ER as I monitored her V/S Q15 without any abnormalities or deviations.............
And with that you and I, along with everyone reading this were forced to pay for this unnecessary transport and subsequent ER evaluation. So yes sir, I should be allowed to say no. No I am not taking to the ER AGAIN. Finish up your antibiotics as previously instructed, and follow up with a primary care physician. If you have new symptoms manifest or your current symptoms progress or worsen, I will take you the NEAREST capable facility. Period. I should not have to acquiesce to her requests and sit there with a smile on my face with the "that's what I'm here for" mantra when I am paying for this and am being taken out of service when I could be actually helping someone else. No Dr. No!
Take note that I said I could be actually helping someone else; I did not say running an "OMG STEMI" or "OMG TRAUMA."
How do you think I feel about my taxes paying for her ride? And the 10,000 others with the same nonemergent needs that will do the exact same thing today accross the country with govt assistance. Can you surmise my attitude? I'm a tax payer too. And that person need to start taking better care of themselves.
You actually just judged your patients a few paragraphs up...
We all do. It's called a scene size up and general impression. Use it in your "whole picture" assessment as I stated above.
Are every patient who calls 911 having a real emergency? No.
We agree!?!?! It's a cold day in ......
Are the etiology of every patient always obvious? No. It's relatively easy to dismiss the obvious meth psychosis until you get the elevated T4 indicating that the psychosis could easily be thyrotoxicosis. It's relatively easy to dismiss the patient with chronic schizophrenia... and then realize that his old records shows 2 large meningiomas putting mass effect on the frontal lobes that the patient was refusing surgery for the year before.
You're all hung ho! What you're suggesting is like the police showing up in full SWAT gear to every petty noise compliant and pointing guns at everyone in the area.
Thoroughly addressed above in the first few paragraphs. If you want to be Dr. House and treat everyone as a medical mystery then go for it. 99.9% you'll be overdoing it though. In addition, the guy with the frontal lobe tumors; someone on scene should be able to indicate some suspicion of that, or perhaps through the investigative techniques of LEOs and medical providers perhaps a medical pendant or other indicator. Like a business card in his wallet for the brain cancer treatment center up the road. Without everyone assuming he's actually having that issue. Also, at psych intake facilities they should have a doctor there and the capabilities to do a few basic labs and procedures.... To find that and refer them to more appropriate care (calling 911 or transporting to ER, etc.)
You say that you're not a psychiatrist, yet you're in a field that, by it's very nature, involves dealing with emergencies in all fields... including psychiatry. You can't pick and choose which fields you want to treat emergencies from.
Again, I addressed this in the first few paragraphs of this reply. A true psych emergency is an emergency. We should do our jobs. Although, you're looking at a very low percentile of patients who are actually having a treatable acute psych episode with a medical cause.
Except FF isn't medicine. Psychiatry is medicine. Some psychiatry is emergency medicine.
Yes, the few I have conceited and offer solutions for or agreed that it is in the EMS realm.
On that note. Are there podiatrists in the ER? Are there Dermatologists in the ER? Podiatry and dermatology are medicine; some are emergency medicine.
I'm tired of typing and beating this dead horse.
