Partner not backing me up.....

[Aidey]

I'm not 100% sure I can agree with this. Yes, HTN is lowered slowly, regardless. However, how many EMT courses cover the difference between urgency and emergency and short of the obvious (i.e. head ache, SOB, other pain, gross neuro deficits), how many signs and symptoms indicating end organ or vasicular damage can an EMT pick up. An EMT (or even medics in most cases and systems, to be honest) isn't going to pick up, for example, papilledema.

I don't really disagree with you. I guess what it comes down to is treatment vs. further assessment. I feel it is misleading to encourage a patient to go to the ER for treatment of HTN, but that it would usually*** be appropriate to encourage them to go for further assessment. Does that make sense?

I agree that 99% of medics aren't going to pick up on papilledema, partially for lack of education, and partially for lack of a opthalmoscope.



***I say usually because you always get those "My BP is 150/86 on my home machine, and it's been getting higher for the last 5 weeks, and I have an appointment with my GP in 3 days. But I don't want to wait because I will have to see my GPs PA, and all they will do is tell me to take a full dose of my medication instead of the 1/2 dose I've been taking because I don't like medications" (True story, went to triage, called my boss and complained that she went to triage).

 

[Veneficus]

and I have an appointment with my GP in 3 days. But I don't want to wait because I will have to see my GPs PA, and all they will do is tell me to take a full dose of my medication instead of the 1/2 dose I've been taking because I don't like medications"

Oh where to begin...

Let me just sum up.

Demand to see somebody who is an MD or DO, accept no lesser substitute when going to "the doctor."

Certainly refuse to pay if you are not seen by the doctor. That usually solves the problem.

 

[46Young]

Arguably off topic, but I have another street tip:

If your pt wants to go to a hospital that is out of range per txp protocol, (and you'd be happy to oblige) the solution is simple. Get OLMC on the phone, and tell them that the pt will refuse tx/txp unless they arew taken to the hospital of their choice. It would be prudent to let the pt know about your strategy, in case OLMC wishes to speak with them.

We used to do this in NYC all the time. We had a ten minute rule. If the pt was reasonably stable, we were allowed to txp to any appropriate 911 receiving facility that was 10 mins or less past the closest appropriate. The result was that the doc would have us advise the pt that we were required to divert to the closest if their condition worsens.

We liked doing this, since we would do multiple jobs in other boroughs after the drop off, since we used AVL's.

 

[Shishkabob]

Am I the only one that thinks BOTH EMTs were in the wrong for not getting ALS involved?


An EMT should not be able to accept a refusal for something cardiac in nature when they can't even get any thing further than OPQRST.

 

[CAOX3]

Except AOx4 is not the only determining factor when it comes to deciding if someone is capable of making their own decisions or not.

To clarify my stance I never have talked a willing party out of going to the hospital no matter how minor the complaint was.

What other determing factors do you consider?

 

[JPINFV]

Had your ethics class yet?

These comments not directed at you but to the gallery.

What about a patient who doesn't have the understanding of the language, the education, or the mental capacity?

What protects you if you tell a patient what could happen to them in medical language that would make Greek and Latin Scholars jealous and they refused?


Many patients and students if asked if they understand something will reply that they do. (even when they don't)

I'll bet I could convince almost any patient to go to the hospital.

It doesn't take much skill as a provider to talk somebody out of a procedure.

The ethics class is one of the ongoing courses that meets once a week for periods over years 1 or 2.

In regards to the rest, "use medical language" and the such, that's why you don't unless the patient understands it. Similarly, yes, patients can lack capacity due to cognitive limits educational limits, and other limits. However, unlike hospitals which have greater access to family members, social services (including normally a department dedicated to coordinating social services called "Social services" employing case managers), ethics committees, and other resources, EMS is generally limited to what resources they have on scene and online medical control who's information is limited to what the crew decides to tell them.

Capacity is one of those things where there's a region of black, completely white, and a huge region of gray. How many drinks is too intoxicated to make a decision? Does a patient with schizophrenia lac capacity? What if it's controlled with medications? What about a patient with autism? Does it matter if it's high functioning form, such as Aspergers? Hence why I always feel a little wary when someone throws out "A/Ox4, GCS 15" as the sole criteria.

 

[JPINFV]

I don't really disagree with you. I guess what it comes down to is treatment vs. further assessment. I feel it is misleading to encourage a patient to go to the ER for treatment of HTN, but that it would usually*** be appropriate to encourage them to go for further assessment. Does that make sense?


***I say usually because you always get those "My BP is 150/86 on my home machine, and it's been getting higher for the last 5 weeks, and I have an appointment with my GP in 3 days. But I don't want to wait because I will have to see my GPs PA, and all they will do is tell me to take a full dose of my medication instead of the 1/2 dose I've been taking because I don't like medications" (True story, went to triage, called my boss and complained that she went to triage).

I'd say that there's a big difference between 150/86 and 192/110.

 

[Aidey]

GCS of 15 and A/Ox4 does not indicate the presence or absence of capacity to give consent on its own. Have you never transported a patient who lacked capacity based on psychological illness who was A/Ox4 with a GCS of 15?

Those are the cases that fall under calling the police for a protective custody order, or the local mental health authority (they can do involuntary orders also).

I'm not disagreeing that there are patients that are AOx4 with a GCS of 15 who can't consent for whatever reason. My issue is the idea that someone who is AOx4 with a GCS of 15 who is exhibiting any symptoms of intoxication by a legal substance, consumed willingly, suddenly gives up all rights to consent.

What about a patient who doesn't have the understanding of the language, the education, or the mental capacity?

What protects you if you tell a patient what could happen to them in medical language that would make Greek and Latin Scholars jealous and they refused?


Many patients and students if asked if they understand something will reply that they do. (even when they don't)

I'll bet I could convince almost any patient to go to the hospital.

It doesn't take much skill as a provider to talk somebody out of a procedure.

This is why I love the language line. I also have the phone number for service to contact the on call ASL interpreter in my phone.

Beyond that, I agree that it is all about communication, and communicating at the patient's level (for lack of a better way to put that). I will sit down and explain how an x-ray works if assuaging a fear of x-rays is what gets the patient to go.

I always make a point of writing what I explained, in the language I explained it in my refusal narrative. I have caught myself having to "translate" what someone else or even myself has said, because I forget that not everyone knows what syncope, or palpitations means.

 

[Veneficus]

The ethics class is one of the ongoing courses that meets once a week for periods over years 1 or 2.

I'm sorry

In regards to the rest, "use medical language" and the such, that's why you don't unless the patient understands it. Similarly, yes, patients can lack capacity due to cognitive limits educational limits, and other limits. However, unlike hospitals which have greater access to family members, social services (including normally a department dedicated to coordinating social services called "Social services" employing case managers), ethics committees, and other resources, EMS is generally limited to what resources they have on scene and online medical control who's information is limited to what the crew decides to tell them.

I have met more than a handful of physicians who talk patients into going to the ED during medical control calls so they can look at the patient rather than simply rely on the EMS report.

I think I have found a use for the new Iphone if they can get the antenna to work.

Hence why I always feel a little wary when someone throws out "A/Ox4, GCS 15" as the sole criteria.

That was my point.

 

[JPINFV]

I'm sorry

Yea... most of what we've had ethics wise has been pretty light weight, however a large portion is this year. The most annoying part is that it's thrown into the "Physician and Society" class which covers things like history of medicine, medicine in the media, and other associated BS.

 

[JPINFV]

Those are the cases that fall under calling the police for a protective custody order, or the local mental health authority (they can do involuntary orders also).

So the police know more about mental health and mental capacity than a medical professional?

 

[Aidey]

Capacity is one of those things where there's a region of black, completely white, and a huge region of gray. How many drinks is too intoxicated to make a decision? Does a patient with schizophrenia lac capacity? What if it's controlled with medications? What about a patient with autism? Does it matter if it's high functioning form, such as Aspergers? Hence why I always feel a little wary when someone throws out "A/Ox4, GCS 15" as the sole criteria.

I do agree with you about that big huge grey area. I think it is a matter of sitting down and talking with your patient, and calling MC if you aren't sure.

With some of those people it takes months of court hearings, evals, etc to determine competency. We are dealing with a lot less time, and it can be a "damned if you do, damned if you don't" situation.

 

[Aidey]

So the police know more about mental health and mental capacity than a medical professional?

Nope. But until such a day that my state determines EMS can issue protective custody orders, they are the ones who have to do it.

Usually it works one of two ways. Someone calls PD, they show up, decide the person can't take care of themselves, and they call us. Or, someone calls us, we show up, determine the patient can't take care of themselves, and then call PD. When PD gets there we tell them why protective custody is justified, and they decide to agree with us or not.

I've never had one not agree. However, I know if we started calling them for every drunk person who is technically alert and oriented, I think PD would start being a lot less cooperative.

 

[Veneficus]

So the police know more about mental health and mental capacity than a medical professional?

That is an ongoing problem.

Many people I know in LE are of the opinion that medics are more capable about making that decision than they are. However in all the places I have been, including places where the coroner doesn't have to be a doctor, the archaeic laws clearly give that power to LE, and make no mention of EMS having it.

But it is a complex issue, not least of which EMS can bill for transport and/or be a private entity, LE is a entity of the state and has less apparent conflict of interest as they cannot bill for taking somebody to the hospital or jail. (not to say that they never abuse that authority)

 

[JPINFV]

But it is a complex issue, not least of which EMS can bill for transport and/or be a private entity, LE is a entity of the state and has less apparent conflict of interest as they cannot bill for taking somebody to the hospital or jail. (not to say that they never abuse that authority)

However physicians can bill for services and, at least in California, enact the same temporary hold as LEOs. Similarly, mobile assessment teams ran by the local psychiatric hospitals headed by an RN can do the same as well.

 

[Veneficus]

However physicians can bill for services and, at least in California, enact the same temporary hold as LEOs. Similarly, mobile assessment teams ran by the local psychiatric hospitals headed by an RN can do the same as well.

Physicians can do that anywhere I have ever been.

But a physician has held a highly respected position is society for a few years Not exactly the same as comparing EMS agencies.

We don't have mobile assessment teams but if you can get an RN out to a scene in a reasonable amount of time sounds good to me.

 

[MrBrown]

But a physician has held a highly respected position is society for a few years ...

Handy tip #371 - do not be in or around medicine when Brown graduates as that may change somewhat

If this guy meets the criteria for being competent to refuse and he does so what's the hubbub, if he dies its his own fault.

Its like my neighbour, he doesnt deserve to have his wireless internet stolen but if he is silly enough to leave it unsecured it should be no suprise when he has it nicked.

 

[JPINFV]

Its like my neighbour, he doesnt deserve to have his wireless internet stolen but if he is silly enough to leave it unsecured it should be no suprise when he has it nicked.

However, is it wrong to sign into the router using the default username and password and be a good Samaritan and secure said router?

 

[MrBrown]

However, is it wrong to sign into the router using the default username and password and be a good Samaritan and secure said router?

Hmm, no, but then again which of us here is Ned Flanders?

 

[JPINFV]

Well... the advantage of securing said router is that, being the person securing it, you are the only one who knows the password. It's more Bart Simpson than Ned Flanders.