Killing Your Patients

[Akulahawk]

Brown wonders how much of "load and go" is underassessment and overtriage.

I might lean more towards overtriage than underassessment. Some might have to do with knowing that there's only so much that can be done in the field with the limited resources available.

Put a Doc on a BLS ambulance and tell that Doc that those supplies are all you have to work with... You're still going to have a number of transports of relatively non-emergent patients simply because the Doc needs more info or the patient needs stuff done that can't be done right there. You'd also see a much larger number of exam and referrals to appropriate resources than is done now.

Personally, I think that overtriage is a BIG EXPENSIVE PROBLEM in the current design of trauma systems today. Clearly it's done so that "something" isn't missed. Personally I think that transports to trauma centers based on mechanism alone happen too often. Injury NEVER happens without a mechanism to cause it. If you can determine the MOI, you then have a good idea where to look for signs of actual injury...

 

[firetender]

How we kill

Let's get back to the original question...

the instructors would tell us how our patient's life lies in our hands, and if we mess up we could easily kill someone.

I heard this in EMT school, but the message was a lot more common in Paramedic school.

So, let's hear it. what mistakes can you imagine an EMS provider making in good faith, that could prove fatal to a patient.

You can make a list and check it twice and try to figure who's naughty and nice and it will get you no closer to avoiding killing someone in the field..

The fact is, the nature of the job is that its practitioners place themselves in innumerable positions to be an agent of the death of other human beings.

Fortunately, in my experience, it generally takes a lot to kill someone in the back of an ambulance. It's usually a combination of factors, only one or two of which were contributed by you. There's what you found at the scene which includes a history behind it all that you can't possibly see, and the future response of the person to what you administer which, when it goes sour, you typically can't predict, and even if you catch your mistake, it's too late.

So, sometimes, you're stuck with a present moment where it really looks like you killed the unlucky patient.

This is how, sometimes, the twisted gods conspire to bring a whole lot of contributing factors together that, alone would not do anything serious, but when you show up you just happen to offer the pressure that collapses the house of cards.

...and it could be anything. It could be any time. It would just happen to be the very wrongest thing at the worst time and you happen to be the poor schmuck that administered it.

So the thread asks, essentially, what is forgiveable and what is innocent? Everything, perhaps except a wilfull intention to harm or a commitment to neglect.

We place ourselves in the paths of others' fate and sometimes, we determine it. It's the nature of the beast.

(The above opinion is that of firetender and does not necessarily reflect the view of EMTLife.com or the views of its Community Leaders.)

 

[MrBrown]

I might lean more towards overtriage than underassessment. Some might have to do with knowing that there's only so much that can be done in the field with the limited resources available.
...

True, but Brown was referring specifically to the mentality of "drag everybody out, throw them in the ambulance and race them to the hospital" mentality which seems to exist in the US because that is what your poorly written, outdated textbook tells you.

 

[DrParasite]

True, but Brown was referring specifically to the mentality of "drag everybody out, throw them in the ambulance and race them to the hospital" mentality which seems to exist in the US because that is what your poorly written, outdated textbook tells you.

Amazing. Brown is not only an expert on EMS and medicine, but he is an expert on the mentality of American EMS, as well as what is written in the the American EMS textbooks. this is amazing because he has never attended an EMS course in the US, and I'm betting he has never stepped foot on a US ambulance nor worked in an Urban or rural American EMS system.

but Brown is an expert in how we do everything wrong. Amazing how that works out.

 

[the_negro_puppy]

Amazing. Brown is not only an expert on EMS and medicine, but he is an expert on the mentality of American EMS, as well as what is written in the the American EMS textbooks. this is amazing because he has never attended an EMS course in the US, and I'm betting he has never stepped foot on a US ambulance nor worked in an Urban or rural American EMS system.

but Brown is an expert in how we do everything wrong. Amazing how that works out.

Brown is probably basing his opinion on the criticism Brown reads about US EMS that other US EMS folk post on here. How now Brown cow.

 

[CAOX3]

True, but Brown was referring specifically to the mentality of "drag everybody out, throw them in the ambulance and race them to the hospital" mentality which seems to exist in the US because that is what your poorly written, outdated textbook tells you.

Actually it probably has more to do with the fear of litigation then anything else.

Somewhere along the way everyone became paranoid about being sued.

Everyone s looking over their shoulder for the boogyman, to a point where it effects patient care. They do it even if it isn't in the best interest of the patient to cover their butt.

 

[johnrsemt]

EMT-B spiking a 500mL bag of Lidocaine instead of NS; and medic giving pt 400mL bolus before it was caught at ED: Basic and Medic both made mistake.
Basic for not making sure he grabbed right bag, medic for not checking it before administering it.
Giving entire 1mg Epi 1:1,000 for allergic reaction because "if they really wanted us to only give 0.15mg to a 3 y/o it would come that way" RN at ED.
Atropine instead of Adenocard, misread.
Adenocard given through 22 g in hand, with no push. "made no sense to push a fast flush afterward, so I didn't" Medic mill training schools, not enough time for them to truly learn what they were doing.
D-50 into an infiltrated AC IV on an unconscious patient. couldn't figure out why it was so hard to push D-50 through a 18 g IV.
Field Subclavian line in cardiac arrest: wasn't in vein; gave 2 liters of fluid, and 40 minutes of ACLS drugs, into a very large pneumothorax.
Ketorlac given instead of Ketamine.

lots of 'mistakes' can hurt or kill a patient or make their life miserable.

 

[Shishkabob]

Most of our meds have reversal agents, or are fairly benign in nature.

I fail to see how your patient is placed at any appreciable risk Every. Single. Time. you administer a med.

Lidocaine. Benign?
Amiodarone. Benign?
Nitroglycerine. Benign?
Etomidate. Benign?
Roc. Benign?
Mag sulfate. Benign?
Atropine. Benign?
Levophed. Benign?
Dopamine. Benign?


That's just a small portion of the medications I carry on my truck, medications I can give any time I please without any sort of oversight.

On top of that, I carry a single (true) reversal agent on my truck, Narcan, and that itself isn't to be considered benign due to the severe consequences that can happen from it's administration.




Most of the medications we carry are poisons to the body, just generally used in a particular manner to hopefully limit bad outcomes.

 

[jonesy0924]

the majority of mistakes are preventable. You should read the label and confirm it before giving it...make sure your truck is equiped right...just double checking will prevent a mistake...all medics will have patients die while on the job but none should be killed by them

 

[usalsfyre]

the majority of mistakes are preventable. You should read the label and confirm it before giving it...make sure your truck is equiped right...just double checking will prevent a mistake...all medics will have patients die while on the job but none should be killed by them

The issue is EMS tends to completely discount engineering controls and discount them. An example is the morphine and epi in similar looking ampules. Yes, it should be double checked. Often times it's not, and refusal to acknowledge this fact is living in a fantasy land.

All of this is compounded by extended shifts. One place I worked even forbid napping during the day, even though the truck I was on commonly ran 20+ calls in a 24hr period. When it was pointed out that this was perhaps suboptimal, it was implied we were lesser men and unable to "work hard without whining".

EMS would benefit greatly from well applied engineering controls. I fear the "aluminum trucks and iron paramedics" mentality will continue for a long time.

 

[jonesy0924]

in total agreement with what was just said. most are over worked...I too worked for an agency that had meds that were packaged very alike. That is when knowing your equipment and truck comes into play. In my case it was the versed and a think benadryl they were in almost the same packaging...we just moved one to a different area. We also had times when we had two different vials witht he same med just packaged different..example we had 10mg in 10ml and another that was 10mg in 1 ml..this is do to buying fron the lowest bidder most of the time..in my opinion knowing what you have and where it is is very important...rest is another big factor....you shhould be allowed to sleep but with restrictions like after 5 pm or during a certain time...we always set a luch time didnt mean we got it but we could nap during that time.....

 

[Lifeguards For Life]

Lidocaine. Benign?
Lidocaine toxicity is treatable

Amiodarone. Benign?
reversable

Nitroglycerine. Benign?
yes.

Etomidate. Benign?
Etomidate has a huge therapeutic index (I think the lethal dose is 20x effective dose?), negligible hemodynamic and respiratory changes

Roc. Benign?
Has anyyone ever overdosed on Roc? It has a relatively short half life, and you can always bag the pt if you cant establish a secure airway

Mag sulfate. Benign?
Adverse effects such as decreased respiratory rate and heart blocks can be reduced with calcium gluconate.

Atropine. Benign?
can be reversed, unlikely to be lethal.

Levophed. Benign?
Didn't know anyone still used this, am pretty sure it is falling to the way side regardless

Dopamine. Benign?
fairly, short half life. If you start to get adverse effect, shut the drip off


That's just a small portion of the medications I carry on my truck, medications I can give any time I please without any sort of oversight.

On top of that, I carry a single (true) reversal agent on my truck, Narcan, and that itself isn't to be considered benign due to the severe consequences that can happen from it's administration.




Most of the medications we carry are poisons to the body, just generally used in a particular manner to hopefully limit bad outcomes.

Yes, "mistakes" are possible, but unlikely to be lethal.

 

[Lifeguards For Life]

Administering .3-.5mg 1:1000 epi IVP for suspected anaphylaxis, even though patient has no respiratory component, just hives.

In our systems epi 1:1 comes packaged in an amp and 1:10 comes packaged in that preloaded plunger thing, so to mix them up would be difficult (granted I know this may not be the case in all systems, though it seems to be fairly common).

 

[jonesy0924]

epi was the same one in amps other in a box for us too

 

[usalsfyre]

you shhould be allowed to sleep but with restrictions like after 5 pm or during a certain time...we always set a luch time didnt mean we got it but we could nap during that time.....

The only thing I disagree with is this. If all other task are complete, I'm probably looking for a flat surface. Because it doesn't matter if I'm asleep at 10:00 in the morning or midnight. The rest and subsequent improvement in decision making is the same.

 

[jonesy0924]

at the time i was working for a fire agency and until 5 you were up...sometimes before that you might get a nap..they had us training and preplanningn and what not...I just got hired with an ems only agency and dont know what there policy is yet ....i agree with you though about sleeping...I was usually the first one to hit the rack when i was working...

 

[Epi-do]

Running in slow-mo doesn't count though...

But it looks good on the evening news.

 

[BEorP]

Nitroglycerine. Benign?
yes.

How is nitro benign?

You can definitely do some damage, particularly if someone is having a RV infarction.

 

[jonesy0924]

or if they have no pressure to begin with

 

[Zodiac]

I witnessed some ER nurses knock a patient's BP down from 130/Something to 30/15 because they apparently applied nitro paste and forgot about it. She was darn near circulatory collapse by the time anybody thought to check on her. Talk about close calls. :glare: