Paramedic Incompetence Question

[AMF]

Not many what? Automatons?

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

Some more than others, I think, is the sentiment.

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

Patient was too comatose to vomit.

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.



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




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 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?

You think boarding caused the patient harm? In adding extra extrication time? The paramedics didn't seem concerned; they were code 1, anyhow.

I'm not saying that all unreliable patients who fall should get back boarded. I'm saying that I'm going to backboard them because I don't want to lose my license. Really pretty straightforward.

I am new, and appreciate your viewpoints.

 

[Veneficus]

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".

Aidey,

I find that it is not the hight of the fall that matters it is the type of impact and the relative condition of the patient.

In a blunt force mechanism, (penetrating is a whole different story)

In order to fracture the body of C-1 you need vertical compression.

C-2 hyperextension.

Other vertabrae flexion or extension. With significant flexion, extension, or soft tissue damage leading to subluxation. (and you will definately notice that)

Also the mid cspine(and lumbar) because of the compartment being narrower and the tissue in it being greater, there is more potential for inflammatory process to cause the cord insult than direct trauma.

Granny falling to the floor with a combination of osteoporosis and osteomalacia from standing could be in serious trouble.

(Psycho feminist note, it is always granny because grandpa dies of an MI at 65 prior to the onset of osteoporosis)

Additionally if the patient is male and has a prior treatment for prostate CA or a female with breast CA, or really anyone with some sort of myloproliferative disorder or pagets disease of bone, could have minor pathologic fractures that are amplified by less significant forces.

 

[STXmedic]

Patient was too comatose to vomit.

Wait, what?

 

[Veneficus]

Patient was too comatose to vomit.

What???!!!

Please, I am trying to give you some perspective and knowledge, but you really need to read a bit more before you say things like that. Both the vomiting centers in your brain and stomach do not require consciousness to function. Infact with relaxation of the lower esophageal spincter tone, it can actually increase the chance of vomiting. The same with the neuro center if it loses inhibition.

You think boarding caused the patient harm? In adding extra extrication time? The paramedics didn't seem concerned; they were code 1, anyhow.

Where to begin...

Boarding causes harm by compromising the ability of a patient to self protect the airway. They can vomit and aspirate or get an obstruction with vomiting that doesn't exist the mouth. (let's call it sub clinical) Which can lean to airway obstruction, pneumosepsis, or chronic fibrotic change. (the later reducing the quality of life and earlier copathologies for the rest of their life.)

It restricts chest wall expansion. (which reduces the effectiveness of breathing.)

It can reduce compartments and cause ischemia (especially to the anterior spinal artery and artery of adamkiewicz resulting in paralysis)

It can also cause pressure ulcers and subsequent complications in those too impaired to feel the pain the early damage causes, tohose with circulatory impairment, and the elderly.

Who gives a crap about prolonged transport time?

 

[Aidey]

Aidey,

I find that it is not the hight of the fall that matters it is the type of impact and the relative condition of the patient.

In a blunt force mechanism, (penetrating is a whole different story)

In order to fracture the body of C-1 you need vertical compression.

C-2 hyperextension.

Other vertabrae flexion or extension. With significant flexion, extension, or soft tissue damage leading to subluxation. (and you will definately notice that)

Also the mid cspine(and lumbar) because of the compartment being narrower and the tissue in it being greater, there is more potential for inflammatory process to cause the cord insult than direct trauma.

Granny falling to the floor with a combination of osteoporosis and osteomalacia from standing could be in serious trouble.

(Psycho feminist note, it is always granny because grandpa dies of an MI at 65 prior to the onset of osteoporosis)

Additionally if the patient is male and has a prior treatment for prostate CA or a female with breast CA, or really anyone with some sort of myloproliferative disorder or pagets disease of bone, could have minor pathologic fractures that are amplified by less significant forces.

Or has/had an eating disorder, ESRD, any variety of diseases that cause malabsorption, or is obsessed with Twilight and never goes into the sunlight because they don't want to sparkle.

I know, you know, and anyone who spends any time doing extracurricular reading knows that MOI isn't a great indicator of actual injury.

It meant it as a literal question. For the non-thinking follow protocol to the letter crowd.

 

[Veneficus]

Or has/had an eating disorder, ESRD, any variety of diseases that cause malabsorption, or is obsessed with Twilight and never goes into the sunlight because they don't want to sparkle.

I know, you know, and anyone who spends any time doing extracurricular reading knows that MOI isn't a great indicator of actual injury.

It meant it as a literal question. For the non-thinking follow protocol to the letter crowd.

My bad, i thought it was a legit question.
I was trying to help.

(I also thought I summed up the absorbtion, liver, renal, and sunlight vit D activation with the osteomalacia nicely )

It is a good day anytime I can figure out how to use less words.

 

[AMF]

What???!!!

Please, I am trying to give you some perspective and knowledge, but you really need to read a bit more before you say things like that. Both the vomiting centers in your brain and stomach do not require consciousness to function. Infact with relaxation of the lower esophageal spincter tone, it can actually increase the chance of vomiting. The same with the neuro center if it loses inhibition.




Where to begin...

Boarding causes harm by compromising the ability of a patient to self protect the airway. They can vomit and aspirate or get an obstruction with vomiting that doesn't exist the mouth. (let's call it sub clinical) Which can lean to airway obstruction, pneumosepsis, or chronic fibrotic change. (the later reducing the quality of life and earlier copathologies for the rest of their life.)

It restricts chest wall expansion. (which reduces the effectiveness of breathing.)

It can reduce compartments and cause ischemia (especially to the anterior spinal artery and artery of adamkiewicz resulting in paralysis)

It can also cause pressure ulcers and subsequent complications in those too impaired to feel the pain the early damage causes, tohose with circulatory impairment, and the elderly.

Who gives a crap about prolonged transport time?

We're not really taught to think like that. We were never taught CIs to Spinal Immobilization. It doesn't mean you're wrong, and it doesn't mean there aren't any, but it does mean that when indicated, there is no excuse for not boarding the patient.
To those who think that a four foot fall on the head (which is about 1000 newtons and has almost a 0% chance of having no horizontal component) is not significant, while I disagree with you, it's kind of irrelevant. The protocol says that head injury patients get boarded. Breaking protocol, at the very least, is cause for disciplinary action.
A practice test question once had me not ked a car accident pt because of concerns over extrication time, which why I asked if that's what you were thinking.

 

[mycrofft]

I disrespect protocols as much as the next person. Honest.

But frankly there are some Frankies and Stella's out there who absolutely need them. And even then the protocols are not going to make them do better, but give the rest of us leverage to get rid of them when they screw up nonetheless.

Every protocol has the invisible ink part that says "unless something comes up that doesn't jibe with this, then you better know what you're doing or listen to someone who does". The more successful education you get the better able you are to recognize when the case has left the protocol rails.

That said, protocols are as subject to bureaucratic snafu as anything else. Universal backboarding was one. Sufficing a cervical collar for a backboard when the latter is needed is another (especially when it says "at technician's discretion", which means "Want a cigarette, blindfold, or KY?").

Maybe what we need are kinder gentler means of minimizing spinal movement during extrication and transport, then it wouldn't be such a bone of contention. We used the aluminum folding "canvas" Ferno Washington litters with straps as with an ambulance litter and sandbags/Philly collar (no head taping, big sandbags) and never had complaints from receiving hospitals that we jiggered someone's spine. But we did use a short board and long board for extrications and transport when the spine was likely very compromised.

PS: Never too comatose to vomit. Or maybe they weren't comatose, then vomited, and NOW they're comatose. You can certainly be too comatose to manage your own vomit.

 

[Aidey]

Boarding causes harm by compromising the ability of a patient to self protect the airway. They can vomit and aspirate or get an obstruction with vomiting that doesn't exist the mouth. (let's call it sub clinical) Which can lean to airway obstruction, pneumosepsis, or chronic fibrotic change. (the later reducing the quality of life and earlier copathologies for the rest of their life.)

It restricts chest wall expansion. (which reduces the effectiveness of breathing.)

It can reduce compartments and cause ischemia (especially to the anterior spinal artery and artery of adamkiewicz resulting in paralysis)

It can also cause pressure ulcers and subsequent complications in those too impaired to feel the pain the early damage causes, to those with circulatory impairment, and the elderly.

Who gives a crap about prolonged transport time?

Just to add to the list.

There is some evidence that c-collars cause a rise in inter-cranial pressure, which is not a good thing, especially if your patient has an actual head injury.

A small cadaver study showed that even when a c-collar was "properly" fitted it caused hyperextension of the neck.

Depending on patient shape and size forcing someone to lay flat can cause excessive lordosis of the lumbar spine. This particularly applies to people with big hips/excess lower body fat and people with kyphosis.

 

[Veneficus]

To those who think that a four foot fall on the head (which is about 1000 newtons and has almost a 0% chance of having no horizontal component) is not significant, while I disagree with you, it's kind of irrelevant.

I accept your challange.

Divide that over the surface area, energy lost in force transfer, and the tissue absorbtion.

I will concede there is probably an extremely small chance providing all the factors line up, but at some point it looks like paranoia.

I really feel bad for the people who call 911 where you are from now. If they only knew what they were getting...

(Not because of you personally, but from the absolute barbaric level of medical practice you are held to.)

 

[Aidey]

My bad, i thought it was a legit question.
I was trying to help.

(I also thought I summed up the absorbtion, liver, renal, and sunlight vit D activation with the osteomalacia nicely )

It is a good day anytime I can figure out how to use less words.

No problem, I should have made it clearer. You did, but I wanted to work that Twilight comment in somehow.

 

[mycrofft]

Don't forget positional asphyxia

Lay me flat and I cannot breathe due to soft tissue and huge tonsils. Others like the morbidly obese have it even worse.

 

[AMF]

I accept your challange.

Divide that over the surface area, energy lost in force transfer, and the tissue absorbtion.

I will concede there is probably an extremely small chance providing all the factors line up, but at some point it looks like paranoia.

I really feel bad for the people who call 911 where you are from now. If they only knew what they were getting...

(Not because of you personally, but from the absolute barbaric level of medical practice you are held to.)

I don't. I'd rather have anything (everything?) you listed than a spinal fracture.

 

[JPINFV]

I guess it's too bad that spinal immobilization doesn't prevent spinal fractures.

 

[Dwindlin]

I guess it's too bad that spinal immobilization doesn't prevent spinal fractures.

Or improve outcomes of people who have them. . .

 

[AMF]

Or improve outcomes of people who have them. . .

Do you have peer-reviewed evidence of that claim? I think I know some people who would like to see it.

 

[JPINFV]

Do you have peer-reviewed evidence of that claim? I think I know some people who would like to see it.

Do you have any peer-reviewed evidence to support the claim that spinal immobilization prevents secondary spinal cord damage?


Spinal immobilization. Recommendation: C, "Recomendation Summary: There is an insufficient amount of evidence available to determine if this intervention should be used or not."
http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=214#Spinal Immobilization

 

[Handsome Robb]

For example, intermediates can't give drugs with olmc.

That's odd. I work as an intermediate and have standing orders for meds...

The fact of the matter here is you don't have to be "taught to think", it should be a spontaneous action. Especially if we want to further this job into a profession.

 

[mrswicknick]

To reiterate what everyone else has said, the glaring problem here is that you are treating the pt as a checklist, rather than looking at the over-arching clinical picture. My biggest problem with this if that you are calling this pt critical, when he clearly is not.

You have trauma secondary to a fall, of low mechanism, with ETOH consumption. You are treating the numbers, not the pt. Yes, your pt has a GCS lower than 15, but can you think of a reason? Look at the situation, the pt is obviously so intoxicated that he urinated all over the floor. Now, assuming you have drank a beer or two before, if you were drunk enough to do that, do you think you would be absolutely alert? No.

Yes, he has a depressed RR, but is he cyanotic? Cool to the touch? His pupils are sluggish... but why? Again, think about what is causing this. Does a 4 foot drop really sound like something that could cause someone to start circling the drain? Or, could it possibly be the fact that he has again, obviously is incredibly intoxicated and all of these are rxns to depressants like ETOH. Also, why in the hell would you put an OPA in a pt who is vomiting? Vomit in an OPA would cause one hell of a blocked airway, and maybe even cause aspiration. And if you are getting full motor function, I would be you his gag reflex is still in tact, and that he is going to vomit the second you try to get it in, and you will have a true airway problem. Why wouldn't you just suction?

How about this, what can a medic do for this pt to help him? Per your protocols this is indicated:

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.'

Was the pt in shock? If not, then #8 is out of the question. Again, manage the airway, but do you think his airway is compromised due to trauma, or due to the ETOH. Again, look at the clinical picture.

Its a matter of looking at the clinical picture, and having some situational awareness. Where I practice, if I called for ALS in this situation not only would my Medics not transport this pt after an evaluation, but they would chew me out post call for not doing exactly what I just mentioned and taking them away from a pt that truly needs their help. Do you really think its a good Idea to take a medic unit OOS just to transport some joe that drank too much?

Dont take this as me bashing you. Just as you were, I was in the same situation not too long ago and followed the book to the dot until I was fortunate enough to sit down with our Senior Medics and even our med director to shed some light on what a true critical pt is. I would advise you try and do the same. I hope rather than looking at this as an attack you will see at as another way to think of the practice of care, and begin to further yourself as an EMT.

 

[systemet]

To those who think that a four foot fall on the head (which is about 1000 newtons and has almost a 0% chance of having no horizontal component) is not significant, while I disagree with you, it's kind of irrelevant.

Any fall on planet earth for a 102 kg object is about 1000N. I think the kinetic injury and the resulting forces on the vertebrae at impact might be more relevant here.

[Not to mention, did his entire body weight impact at the same time, or was perhaps half his body mass supported by the bed, while his head struck the ground?]

The protocol says that head injury patients get boarded. Breaking protocol, at the very least, is cause for disciplinary action.
A practice test question once had me not ked a car accident pt because of concerns over extrication time, which why I asked if that's what you were thinking.

As I said earlier, I'd probably board this patient too if there's no history. I wouldn't trust that the laceration on his head didn't happen from being struck with a bat. I don't trust people in general.

However, if there's clear and reliable evidence that he rolled out of bed, it's hard to see a positive mechanism, even given a very generous interpretation of what constitutes a mechanism.

There's two different arguments at play here:

(1) The argument that it's best for your continuing financial security to remain employed and follow the medical control guidelines in any unclear situation to prevent loss of income / job security.

AND

(2) That it's better you do what's in the best medical interest of the patient.

I don't think anyone is telling you to go out and get fired. They're simply point out that a lot of the patients we immobilise probably shouldn't be immobilising in the first place, that there's almost no evidence behind this practice, and there is proof of potential harm. That simple.