Paramedic Incompetence Question

[Aidey]

Who here has protocols that say a significant fall is 4 feet? Everyone I have worked under usually is something like "20 feet, or more than 3 times body height".

 

[JPINFV]

Your questions make me think. I like that. But as an EMT, thinking is extra. We are legally bound to do what a little book tells us we have to do. My question was really about rank. I didn't think there would any argument about the treatment.

One thing to remember is that protocol philosophy varies greatly. Looking through the forward for Maine's protocols make it looks like Maine is very big on "Our EMS providers are simple technicians who are incapable of thinking for themselves, therefore only OLMC can deviate from our cookbook-ocol."

However, other places will say things like, "We expect paramedics to use their training and good judgment when treating patients in the field and to document situations that vary from the norm," and "Paramedics have the option to perform procedures or administer drugs in the non-shaded areas on their own counsel, or to contact the base hospital for consultation." (emphasis NOT added)

 

[AMF]

Who here has protocols that say a significant fall is 4 feet? Everyone I have worked under usually is something like "20 feet, or more than 3 times body height".

We're taught pt height as a general rule of thumb, but he fell directly on his head.

 

[Aidey]

Or he fell directly on his face.

 

[AMF]

One thing to remember is that protocol philosophy varies greatly. Looking through the forward for Maine's protocols make it looks like Maine is very big on "Our EMS providers are simple technicians who are incapable of thinking for themselves, therefore only OLMC can deviate from our cookbook-ocol."

However, other places will say things like, "We expect paramedics to use their training and good judgment when treating patients in the field and to document situations that vary from the norm," and "Paramedics have the option to perform procedures or administer drugs in the non-shaded areas on their own counsel, or to contact the base hospital for consultation." (emphasis NOT added)

Your perception, based on my understanding, is correct. For example, intermediates can't give drugs with olmc.

 

[DrankTheKoolaid]

re

Well the next time you see your Medical Director, who is the physician that allows you to work under HIS or HER license ask them what they want you to do. Shall we just guess now at what they will say?

 

[Aidey]

I am very new, and I appreciate what you're trying to say. Though, at least in Maine, it doesn't really matter if you're a paramedic or not. You follow protocols, because that's what's legally expected of you.
Generally, when an EMS provider puts something in quotes, it's because they are the words of someone else. I arrived after the patient was moved.
This patient was critical. He was not sitting up by himself. It took several sternal rubs each time for him to open his eyes. His breathing we fine (<12 though), so I was fine with him not being intubated.
He was on the bed, and then he wasn't. His head was on the ground. He can't move. He had a laceration/contusion (an elipse, with diameters 3-4 cm by .5-1 cm) that wasn't there before. Not sure why you think he didn't fall.

Your questions make me think. I like that. But as an EMT, thinking is extra. We are legally bound to do what a little book tells us we have to do. My question was really about rank. I didn't think there would any argument about the treatment.

This statement kind of contradicts itself in this circumstance. What exactly was making him critical?

 

[Tigger]

Since this happens at a college, were you responding with your college's QRS? If so, from what I understand you are not operating as part of a licensed service (or at least that's what Colby College has to say), so the patient was really never "yours," being that the licensed agency on scene is going to be responsible for the patient.

From Colby EMS's website:

The State of Maine does not license college based EMS systems because they do not meet certain logistical requirements ( year-round coverage, mutual aid with surrounding communities, etc...). CER operates from protocols set forth by our overseeing medical facility, the Garrison-Foster Health Center. These protocols are similar to current Maine EMS protocols. CER operates on the Colby College Campus under the direction of the Colby Medical Director.

 

[STXmedic]

AMF, why was this pt critical? From what you've posted, you had a kid who was hammered and rolled out of bed, hitting his head on the way out of bed. Short fall (definitely not a significant distance), and he's plastered. You're at a campus I believe? I would assume you've came across plenty of heavily intoxicated patients. Sternal rubs on intoxicated patients are quite normal. Was there severe, active hemorrhage? Were his pupils blown or unequal? Any vomiting at all? Did you try inflicting pain to extremities? From the info you've provided, there isn't really anything to indicate this is a critical patient.

 

[AMF]

Since this happens at a college, were you responding with your college's QRS? If so, from what I understand you are not operating as part of a licensed service (or at least that's what Colby College has to say), so the patient was really never "yours," being that the licensed agency on scene is going to be responsible for the patient.

From Colby EMS's website:

We have those things and are licensed as a service. I've seen the certificate. I didn't know you could provide medical care outside of a service as an EMT.

We consider a trauma patient that is not wnl in at least 2 areas (from BP, HR, RR, BGL, SpO2, or AMS as determined by the GCS) to by critical.

 

[STXmedic]

We consider a trauma patient that is not wnl in at least 2 areas (from BP, HR, RR, BGL, SpO2, or AMS as determined by the GCS) to by critical.

So a little old lady who's a chronic smoker, BP of 96/50 and a RR of 24ish, maybe pulse ox of 93%, is considered critical? How about a female cross country runner who's got a similar BP and a pulse of 42. Is she critical as well?

 

[AMF]

AMF, why was this pt critical? From what you've posted, you had a kid who was hammered and rolled out of bed, hitting his head on the way out of bed. Short fall (definitely not a significant distance), and he's plastered. You're at a campus I believe? I would assume you've came across plenty of heavily intoxicated patients. Sternal rubs on intoxicated patients are quite normal. Was there severe, active hemorrhage? Were his pupils blown or unequal? Any vomiting at all? Did you try inflicting pain to extremities? From the info you've provided, there isn't really anything to indicate this is a critical patient.

No vomiting at all (which I see as a red flag), light hemorrhage, no response to pain in the extremities, and it took several sternal rubs for him to even open his eyes. He localized, but mvmt was sluggish at best.

Not that it matters if he was critical or not. Green 12 of the MEMS protocols look like this:
"Head Trama
Basic
1. Immobilize entire spine on long spinal immobilization device.
2. O2 as appropriate
...
Intermediate/Critical Care/Paramedic
7. IV en route
8. If shock present, perform fluid challenge to maintain BP > 90 mmHg
9. Cardiac Monitor
10. Manage airway as needed. See 'Blue 3 and 5.'
"
There is no paramedic-specific response. There is no "Immobilize if appropriate." I just want to know if I can not board an unreliable patient with an unwitnessed fall with visible laceration/contusion and say "the responding paramedic told me not to and since I'm just a cookbook technician who can't think for myself, I thought it'd be okay."

 

[AMF]

So a little old lady who's a chronic smoker, BP of 96/50 and a RR of 24ish, maybe pulse ox of 93%, is considered critical? How about a female cross country runner who's got a similar BP and a pulse of 42. Is she critical as well?

No. They are wnl. Normal limits are per captia. I'm not sure why his critical condition matters. If either of your hypotheticals fell on their head and were unreliable, they'd get boarded as well.

 

[STXmedic]

I'm not arguing that your patient shouldn't have been boarded. Personally, I probably would've boarded him as well. Our SMR clearance is also excluded by an unreliable patient (and we had a case here very similar to this that actually did have a spinal injury). It just seems like the condition of this patient is being mildly exaggerated, whether on purpose or out of ignorance.

 

[STXmedic]

No. They are wnl. Normal limits are per captia. I'm not sure why his critical condition matters. If either of your hypotheticals fell on their head and were unreliable, they'd get boarded as well.

See, so y'all DO have the ability to use professional judgement, at least to an extent. Don't sell yourself short, guy. EMTs are still required to think instead of just "See this, do that"

 

[Handsome Robb]

AMF, why was this pt critical? From what you've posted, you had a kid who was hammered and rolled out of bed, hitting his head on the way out of bed. Short fall (definitely not a significant distance), and he's plastered. You're at a campus I believe? I would assume you've came across plenty of heavily intoxicated patients. Sternal rubs on intoxicated patients are quite normal. Was there severe, active hemorrhage? Were his pupils blown or unequal? Any vomiting at all? Did you try inflicting pain to extremities? From the info you've provided, there isn't really anything to indicate this is a critical patient.

You beat me to the punch. Drunko McGee took a tumble and is heavily intoxicated. I don't see critical anywhere in here.

 

[AMF]

See, so y'all DO have the ability to use professional judgement, at least to an extent. Don't sell yourself short, guy. EMTs are still required to think instead of just "See this, do that"

Not many would agree with you

 

[Veneficus]

I am very new, and I appreciate what you're trying to say. Though, at least in Maine, it doesn't really matter if you're a paramedic or not. You follow protocols, because that's what's legally expected of you.
Generally, when an EMS provider puts something in quotes, it's because they are the words of someone else. I arrived after the patient was moved.
This patient was critical. He was not sitting up by himself. It took several sternal rubs each time for him to open his eyes. His breathing we fine (<12 though), so I was fine with him not being intubated.
He was on the bed, and then he wasn't. His head was on the ground. He can't move. He had a laceration/contusion (an elipse, with diameters 3-4 cm by .5-1 cm) that wasn't there before. Not sure why you think he didn't fall.

Maybe somebody hit him? Maybe he hit his head puking in the toilet?

If he fell or not is not my issue, the question is does he have a significant enough potential to reasonably cause a catastrophic injury and was there any physical exam finding that supported it?

Ask yourself:

What do you consider a critical patient?

What do I consider a critical patient?

I'll bet they are not even close to matching.

But as an EMT, thinking is extra..

Not directed at you , but sometimes I wonder if it is even possible EMTs can think anymore. I remember when they capable providers.

We are legally bound to do what a little book tells us we have to do.

I know what you were taught.

I know why you were taught that way.

I know you are considered an adult learner and the instruction of your original teacher in your mind is the highest credible source and I am just some moron in typing on the internet telling you something diametrically opposed to brainwashing you got in EMT class.

I also know you are new, and probably haven't seen all that many patients, much less critical ones.

So in your mind any patient that scares you or otherwise causes stress is critical.

But I would like you to reread my post in response to Corkey, I don't recall the number, but it is the one above JPs football picture. Then think about it.

If you harm a patient, you are wrong. Nevermind the lawsuit, you might harm many and never get sued. But if you cause somebody injury or exaserbate their illness for that little piece of mental security or to satisfy a standing order that cannot possibly account for every circumstance, you are worse than no help at all.

You seem to elevate the position of doctors, of which I know one or two , Some I like and hold the highest respect for I disagree with on occasion. But I don't know any that would actually have you carry out a treatment without regard as to what that treatment would do to a given patient.

"It's a do no harm" thing.

Now I don't honestly care if your protocol says stick as a pole in the patient's a$$ and spin them around on it, you are called to and trusted to do what is in the best interest of your patient by the highest medical authority. The patient. You have a responsibility to them and that trust to think about what you are advising them and doing to them.

It is not a bonus.

I think you should go demand your money back from an instructor who did not actually teach you, but instead made you memorize the fears and anxieties they projected upon you.

You may find your career much longer and more rewarding with the calm that knowledge brings.

Honestly, if you are in medicine to simply do as you are told, you may find better pay in a factory.

I didn't think there would any argument about the treatment.

I can argue treatment with just about anyone.

But that is not the point.

Did you know that spinal precautions in a hospital consist of a c-collar and a soft matress?

In fact, I cannot recall one instance of a spineboard being used in any medical environment outside of EMS. Do you think the principles of medicine change when you leave the ivory tower called a hospital?

I am truly sorry your State thinks you are too stupid to make a decision. It is not the only one and a disservice to you as a person.

But ask yourself, you just told me thinking was optional. So are they really at fault if a majority of the people providing care think that way?

Wouldn't that make you part of the problem?

 

[abckidsmom]

Not many would agree with you

Not many what? Automatons?

Regardless of your level of care, thinking is completely required in this job.

 

[Aidey]

Did you know that spinal precautions in a hospital consist of a c-collar and a soft matress?

In fact, I cannot recall one instance of a spineboard being used in any medical environment outside of EMS. Do you think the principles of medicine change when you leave the ivory tower called a hospital?

We were called to do a transfer from a smaller ER to a children's ED for a 9yo with possible SCIWORA. The ER requested we bring a backboard. We make contact, and I ask why the backboard. The RN said that she assumed we had to use it, I said nope unless the neurologist said so. His response was "Why the hell would you want to do that?". He did not get transported on a backboard.