Stressed guys messdd up on some calls.

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NateJack745

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I guess I cannot argue with someone who does not know what they do not know. I already clearly explained reasons outside of possible treatments on why you should complete your own assessment. However, if you and others wish to continue to find justifications for doing otherwise, justifications for doing less than as providers in the field, then carry on. Just know that arguing for better pay, better scope, more respect...is simply a dream when these practices and mindsets continue.

Imagine a nurse saying "well the doctor is just a few feet away, and they will assess the patient quickly, and they are usually in the room within 2-3 minutes, so I will just hold off on my assessment cause I really cannot do anything anyways and nothing is going to change that patient's condition".

And go read this if you are going to rely on a radial pulse determining a BP to be "at least 80", which somehow does not seem all that concerning to you. And no mention of the patient's MAP in your assessment.

Spot on. EMS professionals confuse me so much. They are disgruntled that people treat them like taxi drivers but act like taxi drivers. They are disgruntled that they aren't paid what they are worth but don't behave in a way that earns what they are worth.
 

NateJack745

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I think there was confusion on what I posted, that goes hand in hand with what DrParasite said. My suggestion isn't to do nothing. While assessing vital signs is part of an assessment, it is not the only part of assessment. I grab radial on every single patient, regardless of length of transport or complaint. This alone tells me so many things. Heart rates/regularity/quality. Skin temperature and condition. That there is a blood pressure above 80. I am also in those two minutes asking questions that assessed mental status and forming a general impression. I can also assess in this time the respiratory effort. So of the basic vital signs, what have I not assessed, maybe a BP?

I agree that our job is more than A to B. We should consider what our actions have on the longer term for the patient. On a patient that appears stable on initial impression and has a two minute transport, there is not a benefit to waiting around to getting a detailed assessment prior to transporting. Maybe this is different as a BLS provider, than an ALS provider. However, if I assessed the patient's blood pressure and its 200/100, as a BLS provider what am I doing for that? I don't carry medication or treatment that can lower that. My best plan of action for that is rapid transport. And that patient's blood pressure would have still be 200/100 regardless of whether or not I wasted time to assess it.

Normally, if I had a transport time this short, I would assess vitals upon arrival at the triage station. Almost all my local hospitals have a vital signs machine available as soon as we walk in. A this point if our transport was only 2-4 minutes, assessment of the patient is still occurring within the first 10 and maybe even the first 5.
Couldn't disagree with you more. Do you really still believe that a radial pulse guarantees a systolic of 80?? I've seen many patient's who have a strong radial pulses who are clearly hypotensive.

There is an absolute benefit to staying on scene long enough to do an appropriate assessment. A quick assessment leads you to believe that a patient has a psychiatric illness. A more thorough assessment indicates that the patient is experiencing delirium tremens - I've seen medics biff this one dozens of times. An extra 5 minutes could make or break the outcome for this patient. A quick assessment might result in the belief that taking the patient to a psychiatric hospital is a good idea. The reality is, it's a terrible idea and a withdrawal seizure in a psych hospital isn't going to be managed well.

So many EMS professionals indulge in Occam's Razor: Looks like a duck, walks like a duck, talks like a duck - it's a duck. Except when it's not. @ZombieEMT I would recommend reviewing Diagnostic Errors with Cognitive Disposition to Respond.
 

DrParasite

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Just know that arguing for better pay, better scope, more respect...is simply a dream when these practices and mindsets continue.
Ehhh, it's more about knowing your limits, and doing what is in the best interests of the patient. delaying definitive care rarely helps the patient unless you have an intervention in your toolbox that can fix the issue. Spending 10+ minutes on scene with a "stable" GSW to the torso, while you load the patient into the ambulance, assess the patient, start two IVs, and reassess, when the trauma center is <5 minutes away? Yeah, fix life threats if you can, but what does the patient really need? give you a hint: it's not a prehospital provider.

I will reiterate: we, as EMS providers, need to be better at performing a patient assessment. If you have a stable patient, set up camp. If you have a sick patient, start making your way to the truck, especially if you can't fix the problem.

My pay was decent (20/hr), my scope was ridiculously small, but my respect level was probably above average, at least among the hospital personnel that I interacted with.

By the way, have you ever seen an experienced ER triage nurse do an assessment? it's pretty basic (mechanical vitals, patient weight, ask some questions, that's about it). You ever see a triage nurse do an assessment on a sick patient? its called if they look sick, call for a bed in the back, maybe get some vitals, and escort them back. When my son had his last croup attack, as we walked in the door, she saw him, heard him, and was already on the phone to get a bed ready; I was worried he was going to need to be admitted to the PICU or intubated (and thankfully he was fine with some steroids, which we told the peds attending was all he needed). I also saw a burn patient get dropped off at the ER doors (construction accident, worker got caught on a small LPG tank explosion). I believe her exact assessment involved saying "holy ****", getting his name, and then having him lay on an ER bed before he was wheeled back to shock trauma.

There is something to be said for knowing your limitations, and knowing when you need help. Using your example of "well the doctor is just a few feet away, and they will assess the patient quickly, and they are usually in the room within 2-3 minutes" if the patient looks sick, the nurse will often drag the doctor in, or initiate their standing orders while screaming for someone else to drag the attending in.
Couldn't disagree with you more. Do you really still believe that a radial pulse guarantees a systolic of 80?? I've seen many patient's who have a strong radial pulses who are clearly hypotensive.
Well, my FD captain (who has an EMS instructor credential) told me in our last class, so it must be true...

Actually, I will agree that it is has been clinically debunked, but would you agree that if you surveyed 100 people with radial pulses, 95 of them would have a systolic above 80? and if you surveyed that same 100 people, all of whom were asymptomatic, 99 of them would have a depend BP (at least systolic above 80)? Doesn't replace an actual BP cuff, but as a rough estimate?

But @ZombieEMT , he's absolutely right, there is no guarantee that the BP is above 80 just because they have a radial pulse... But if they don't have a radial pulse, I will assume it's below 80, and identify the patient as potentially really sick, unless the rest of my assessment shows otherwise.
So many EMS professionals indulge in Occam's Razor: Looks like a duck, walks like a duck, talks like a duck - it's a duck. Except when it's not. @ZombieEMT I would recommend reviewing Diagnostic Errors with Cognitive Disposition to Respond.

 

akflightmedic

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It is cute that you take an example and then extrapolate to the absurd...a GSW to the torso, you know, the exact thing we were NOT talking about. Something about logical fallacies comes to mind now.

You then again default to the "if not sick, set up camp, if sick, start towards the hospital"..at which point I will reiterate...sometimes you do NOT know they are sick until you perform the assessment, which includes vitals. Stop making excuses for doing less than what we should by reaching for extreme hyperbole.

It is also cute that you ask me...if I have ever seen an ER Nurse do triage. You know, me...the guy with RN behind his name. The guy who works in an ER and also covers triage.

Your pay was normal for the area you were in, your perceived respect is NOT what we were discussing, we were discussing the profession as a whole. Same with wages, same with scope.

And yes, I know what nurses do when the patient "looks sick". You are talking to a nurse! LOL

 

NateJack745

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Ehhh, it's more about knowing your limits, and doing what is in the best interests of the patient. delaying definitive care rarely helps the patient unless you have an intervention in your toolbox that can fix the issue. Spending 10+ minutes on scene with a "stable" GSW to the torso, while you load the patient into the ambulance, assess the patient, start two IVs, and reassess, when the trauma center is <5 minutes away? Yeah, fix life threats if you can, but what does the patient really need? give you a hint: it's not a prehospital provider.

I will reiterate: we, as EMS providers, need to be better at performing a patient assessment. If you have a stable patient, set up camp. If you have a sick patient, start making your way to the truck, especially if you can't fix the problem.

My pay was decent (20/hr), my scope was ridiculously small, but my respect level was probably above average, at least among the hospital personnel that I interacted with.

By the way, have you ever seen an experienced ER triage nurse do an assessment? it's pretty basic (mechanical vitals, patient weight, ask some questions, that's about it). You ever see a triage nurse do an assessment on a sick patient? its called if they look sick, call for a bed in the back, maybe get some vitals, and escort them back. When my son had his last croup attack, as we walked in the door, she saw him, heard him, and was already on the phone to get a bed ready; I was worried he was going to need to be admitted to the PICU or intubated (and thankfully he was fine with some steroids, which we told the peds attending was all he needed). I also saw a burn patient get dropped off at the ER doors (construction accident, worker got caught on a small LPG tank explosion). I believe her exact assessment involved saying "holy ****", getting his name, and then having him lay on an ER bed before he was wheeled back to shock trauma.

There is something to be said for knowing your limitations, and knowing when you need help. Using your example of "well the doctor is just a few feet away, and they will assess the patient quickly, and they are usually in the room within 2-3 minutes" if the patient looks sick, the nurse will often drag the doctor in, or initiate their standing orders while screaming for someone else to drag the attending in.

Well, my FD captain (who has an EMS instructor credential) told me in our last class, so it must be true...

Actually, I will agree that it is has been clinically debunked, but would you agree that if you surveyed 100 people with radial pulses, 95 of them would have a systolic above 80? and if you surveyed that same 100 people, all of whom were asymptomatic, 99 of them would have a depend BP (at least systolic above 80)? Doesn't replace an actual BP cuff, but as a rough estimate?

But @ZombieEMT , he's absolutely right, there is no guarantee that the BP is above 80 just because they have a radial pulse... But if they don't have a radial pulse, I will assume it's below 80, and identify the patient as potentially really sick, unless the rest of my assessment shows otherwise.


I’m not sure I follow what you’re asking me to agree with or disagree with. Nobody disagrees that an asymptomatic patient should have a normal blood pressure.

I’ll simplify it. If you’re using the presence or absence of a radial pulse to tell you if your patient is sick or not sick, you don’t know what you’re doing.
 

Akulahawk

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By the way, have you ever seen an experienced ER triage nurse do an assessment?
Yes. I'm also an experienced ED RN and I do triage too. Not all of that respond here are just Paramedics. Some of us do flight, ground, ED, or ICU work as nurses... we see sick patients a LOT more often than most medics do and you might be surprised how quickly we recognize when we have one that's sick. Sometimes we don't get vitals immediately at triage because the sick is obvious but vitals WILL be obtained once in a room along with a bunch of other stuff and the assessment is ongoing the entire time. Translate that to an ambulance and I might not get vitals immediately on scene, but I will get what I can in the ambulance as that's part of the assessment process, even if the ED entrance is literally across the street. BTDT. I might get VS of weak/thready tachy pulse around 140, BP 88/P, RR >30 shallow and labored... but it gets done before I get to the hospital and my assessment continues through hand-off to the ED.
 

DrParasite

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It is cute that you take an example and then extrapolate to the absurd...a GSW to the torso, you know, the exact thing we were NOT talking about. Something about logical fallacies comes to mind now.
it's cute that you don't understand that this is exactly what we are talking about. knowing your limitations, knowing what you can and cannot do anything about. And knowing that sometimes, the best thing you can do to the patient is transport to definitive care, because nothing you do is going to have any affect on the patient's outcome.
It is also cute that you ask me...if I have ever seen an ER Nurse do triage. You know, me...the guy with RN behind his name. The guy who works in an ER and also covers triage. And yes, I know what nurses do when the patient "looks sick". You are talking to a nurse! LOL
Actually, that analogy was more for those who were not a nurse... I would assume that you would know that a nurse does exactly as I describe, because you are a nurse (again, something I knew). but it's cute that you would think that because a nurse does it, a prehospital provider shouldn't act in the exact same way (despite you saying you do that exact thing). I know you're a relatively new nurse, maybe you should ask a more senior nurse for a refresher if you have forgotten?
Your pay was normal for the area you were in, your perceived respect is NOT what we were discussing, we were discussing the profession as a whole. Same with wages, same with scope.
It's cute that you are making incorrect assumptions about me. My pay was actually quite high compared to the other EMS providers in the state. Based on what I have read here, it was actually quite high compared to others nationwide.

It's cute that you completely disregard how I was respected by my fellow healthcare colleagues, yet complain that the industry doesn't get enough respect. Maybe it was a local thing, and only EMS providers were actually respected in healthcare, every other state didn't? I mean, that sounds pretty far fetched, or maybe I was mature enough of an adult to not whine about not being respected, and demonstrated my competence level to MDs and RNs to the point where they respected me? And my agency's reputation for high hiring standards, resulted in we being known as one of the better and more respected EMS agencies in the region? And if you didn't get that respect, maybe that's a you issue?

I’ll simplify it. If you’re using the presence or absence of a radial pulse to tell you if your patient is sick or not sick, you don’t know what you’re doing.
If that's the ONLY factor you are using to determine sick vs not sick, then I agree, you have no idea what you are doing.

Sometimes we don't get vitals immediately at triage because the sick is obvious but vitals WILL be obtained once in a room along with a bunch of other stuff and the assessment is ongoing the entire time.
That's exactly what I said... vitals will be taken, once in a room along with a bunch of other stuff. I am not saying the patient never needs vitals taken; however, you should assess your patient during the entire time. Sometimes those vitals get taken in the ER.
Translate that to an ambulance and I might not get vitals immediately on scene, but I will get what I can in the ambulance as that's part of the assessment process, even if the ED entrance is literally across the street. BTDT. I might get VS of weak/thready tachy pulse around 140, BP 88/P, RR >30 shallow and labored... but it gets done before I get to the hospital and my assessment continues through hand-off to the ED.
not to get down too much of a rabbit hole... but if your patient's vitals are that abnormal, and you are across from the ED entrance, what interventions are you going to perform? start an IV, give some fluid, throw on some oxygen, maybe a 12 lead, head to toe assessment, full history and background (SAMPLE and OPQRST)? maybe some meds based on what you find?

Do you think the patient's outcome will be different if hospital security picks up the patient, puts them in a wheelchair, and rolls them into the ER?
 

akflightmedic

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I think you are being intentionally obtuse, refusing to admit that your are off base here, yet continually trying to find clever ways to make yourself appear and sound "right" in regards to justifying NOT doing a full assessment. All of which is simply poor form.

And then implying the nurse example is not relevant as I am a "newish" nurse while disregarding the 26 years which preceded that title which involved experience/exposure far greater than the typical RN or even the typical paramedic exploits all again in a failed effort to irrationally try to sweep away an assessment prior to transport based on distance to facility. This is quite moronic any way you slice it.

For your pay, provide the state/city in question and the year in question.

You were "disrespected" because you advocated for doing less than what should be a normal scope of practice. Heck, you even continue to justify it. Absolutely, if you are going to support doing slack effort pre-hospital, then it absolutely is your peers obligation to correct you, attempt to correct you, and advocate against you in what you "perceive" to be disrespectful. Bear in mind, I kept it mostly professional and did not ask the "WTF is wrong with you" question until you repeated rather dense trains of thought several times in a row.

But go ahead, refuse to acknowledge this is flawed thinking. Continue to insist you are correct. I expect nothing less, however myself and others have weighed in with enough rational counter opinion to try and influence those who are new or inexperienced that there are better ways and practices for proper patient care and hope they see the contrast and choose the proper path.
 
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DrParasite

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@akflightmedic You've insulted me, and are making statements about me that are factually incorrect about me. I have pointed out the flaws in your opinion and ignored your condescension. And despite your repeated claims, I haven't been disrespected; if you have, that's a you issue.

And I was factually accurate about you, where you are a newish nurse (despite you falsely implying that you were a veteran nurse with decades of nursing experience).

I can give you facts, but if you don't like them, you just start with personal attacks. That says a lot more about you than me, and that's ok.

When it comes to prehospital care, there is only so much we can do. Knowing their limitations is one of those common failures I see in EMS, when providers don't realize that sometimes the best thing they can do for the patient is transport them to definitive care, especially when the patient is experiencing a medical condition that you can't fix. Despite 26 years, you don't seem to understand that.

I've tried to educate you, and try to get you to actually use your brain to understand the process, and you have failed, and I'm done trying. Have a great weekend.
 

ffemt8978

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And that's enough of this one.
 
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