What should have been done?

[VentMedic]

seriously? he's a first responder, probably new to the field and at least he came here to learn what went wrong, cut him some slack. I agree it was wrong, and mistakes were made but it's a learning process, I was there in his shoes once, as I;m sure you were too, unless your one of those medics who thinks they never made a mistake, boy I know I have made some, but I;ve learned from each and every one, and thankfully no pt was harmed seriously in the process.

We don't know if the patient was harmed or not. No harm is your assumption. The OP may not know until the girl's attorney contacts him.

This thread should have a sterner message because the OP doesn't seem to realize what a bad situation he is in for this position of FR with no backup coming. He is relying on a piece of paper to protect him from any legal liability. This is not a bashing of him as a personal attack or his one mistake. This should have been an eye opening experience for him as his post does point to the fact he has little medical knowledge and should not have been placed into this positon with the responsibilty of determining whether at ambulance should transport or accept a refusal from a patient under questionable circumstances.

By this statement, he still has a lot to learn.

I believe my only mistake was not watching my partner,

If that was my daughter, after learning she was going to be okay, I would focus on getting an attorney if nothing else other than to make a change in that system or a change in attitudes. There should be an expectation about the level of care coming to your assistance when you dial 911 or even campus EMS. I would be questioning what type of emergency medical care our kids have access to in college. If the only care you are getting is a FR and the public is putting their trust unknowingly into their hands to make determinations of transport or not, that system is flawed. Is it too much to have even an EMT-B available? I would hope the majority of the country does provide at least an EMT-B when they use the term "EMS".

What happens when they get a patient with "the flu" and no transport is done except maybe to wait for a taxi? What do you think are the consequences of meningitis on a college campus?

I would rather have the OP start asking the questions that have been presented here to his superiors and to review his P&P book rather than spending his senior year tangled up in a legal case.

There are some posts where hand holding and soft, gentle words are necessary. This is not one of them.

Yes, Paramedics, Nurses and RRTs do make mistakes and the consequences can be very serious for both the patient and the provider.

Again, EMS is about patients and their lives. Regardless of your level, one must think about providing the best medical care possible for the patient.

 

[ClarkEMS]

We never find out the end result with our patients, but I looked up all the symptoms last night and did some research into some possible things that it could have been and I am most definitely sure that it was appendicitis. I will never know for sure, but every symptom I saw in the patient was listed under appendicitis. I think in trying to explain this case I wasn't very clear on what exactly happened as is the case usually when trying to remember every detail. I agree mistakes were made which is why I put this up here in the first place because I like getting feedback and I don't think that I am a medical god who knows all and never makes mistakes. I am a FR in training to be an EMT on a campus squad that I already know has saved lives with their quick response time and contact with ambulance service. We are probably the most under appreciated, ignored, and put down medical group, but we still go out there and try to help people and organize a successful emergency care situation. I want to make my squad better and make my response to situations better, hence going to an EMT class. This was my first time in a position of command on the squad and I think I did a pretty good job in the circumstances and I understand areas of improvement which I will definitely take into consideration for my next call. Thank you EMTLife because without you guys I wouldn't have a place to get good advice for the future.

 

[medicdan]

We don't know if the patient was harmed or not. No harm is your assumption. The OP may not know until the girl's attorney contacts him.

This thread should have a sterner message because the OP doesn't seem to realize what a bad situation he is in for this position of FR with no backup coming. He is relying on a piece of paper to protect him from any legal liability. This is not a bashing of him as a personal attack or his one mistake. This should have been an eye opening experience for him as his post does point to the fact he has little medical knowledge and should not have been placed into this positon with the responsibilty of determining whether at ambulance should transport or accept a refusal from a patient under questionable circumstances.

By this statement, he still has a lot to learn.


If that was my daughter, after learning she was going to be okay, I would focus on getting an attorney if nothing else other than to make a change in that system or a change in attitudes. There should be an expectation about the level of care coming to your assistance when you dial 911 or even campus EMS. I would be questioning what type of emergency medical care our kids have access to in college. If the only care you are getting is a FR and the public is putting their trust unknowingly into their hands to make determinations of transport or not, that system is flawed. Is it too much to have even an EMT-B available? I would hope the majority of the country does provide at least an EMT-B when they use the term "EMS".

What happens when they get a patient with "the flu" and no transport is done except maybe to wait for a taxi? What do you think are the consequences of meningitis on a college campus?

I would rather have the OP start asking the questions that have been presented here to his superiors and to review his P&P book rather than spending his senior year tangled up in a legal case.

There are some posts where hand holding and soft, gentle words are necessary. This is not one of them.

Yes, Paramedics, Nurses and RRTs do make mistakes and the consequences can be very serious for both the patient and the provider.

Again, EMS is about patients and their lives. Regardless of your level, one must think about providing the best medical care possible for the patient.

Okay, I am going to take a stab at responding to this. I know ClarkEMS well, know his campus, and have a good sense of campus EMS as a whole from my own campus.

Clark runs an all-FR service, and the understanding under which they accept RMAs is that they say, "I have no way of diagnosing what is/could be wrong with you right now. You need to be assessed by an ER Physician, and recieve care in an ER. We are happy to call an ambulance for you, and you will be transported to the hospital (0.7 miles away), or you can sign here, refusing medical attention/urgent transportation to the ER. For all I know, without this assessment and treatment, your condition may worsen, and you may die."

If the patient signs, the campus police department likes to make sure that the student gets some medical attention, so will provide a taxi to get the student to the hospital. That is separate from EMS.

ClarkEMS functions as a QRS/EFR, not an ambulance service. They provide quick response times, care for minor injuries not requiring transport, and, after dispatching BLS/ALS, provide care on scene to treat life threats.

As far as I understand it, there is a standard BLS response for every call, and the truck keeps coming unless they are canceled by the FR crew. In that case, the FR crew DOES have a backup coming, BLS at the minimum. It's also worth noting that the majority of the corps is now enrolled in an EMT course, and they have aspirations, over time, to create a BLS service. They are working to increase their communal knowledge, constantly working to improve the patient care provided.

I know to you, campus EMS appears as pure amateurs frolicking with patient care under the guise of EMS, but on most campuses, there is real leadership, real call and case review, real medical direction, real protocols, and calls that are more various than just drunk students.

The Campus EMS group I am associated with takes education seriously. We conduct written and skill reviews of all members regularly, making sure that all members maintain rarely-used skills and knowledge. We offer a different 2-3 hour continuing education class each week. Twice a year, we simulate an MCI or large MVA or gas leak, etc, and bring in the entire corps as responders. As well, many of our mid- and upper- level members work off campus, and in fact, a requirement for promotion is a certain amount of off-campus experience. My service has an ambulance license from the state—we are accountable to them, we were inspected two weeks ago.

Again, no more volly debate…I am happy to have a discussion about the value or merits of college EMS squads, but on a separate discussion, away from this case review.

 

[Sapphyre]

, but I looked up all the symptoms last night and did some research into some possible things that it could have been and I am most definitely sure that it was appendicitis. I will never know for sure, but every symptom I saw in the patient was listed under appendicitis.

I'm going to keep my opinion of campus EMS, and First Responders being about to make decisions as to whether EMS is needed to myself....

But, the above quote needs to be addressed. There is NO way you can be most definitely sure that someone has appendicitis. I couple years ago I had 3 nurses, 2 ER IM/GP docs and 2 surgeons absolutely convinced I had appendicitis. When they got inside to take care of it, I had yet another ruptured ovarian cyst. Even the doctors in the hospital with access to a lab, and imaging often times can't be sure. That is why we don't get to decide that it's "just" anything....

 

[VentMedic]

As far as I understand it, there is a standard BLS response for every call, and the truck keeps coming unless they are canceled by the FR crew. In that case, the FR crew DOES have a backup coming, BLS at the minimum. It's also worth noting that the majority of the corps is now enrolled in an EMT course, and they have aspirations, over time, to create a BLS service. They are working to increase their communal knowledge, constantly working to improve the patient care provided.

You contradict yourself here.

ClarkEMS functions as a QRS/EFR, not an ambulance service. They provide quick response times, care for minor injuries not requiring transport, and, after dispatching BLS/ALS, provide care on scene to treat life threats.

How much time is wasted and other mistakes have been made by relying on a FR to determine the need for an ambulance before dispatching it?

If the ambulance had been dispatched along with the FRs in this scenario, we probably wouldn't be having this discussion.

Read how the OP explained it.

Clark runs an all-FR service, and the understanding under which they accept RMAs

RMA - Refuse Medical Advice? If the patient is accepting your suggestion to take a taxi, they are taking your medical advice. The FR "advised" me to take a taxi because it was free. That is still advice to get one to the ED. It is not a refusal of care. By suggesting the patient take a taxi, you have made the assessment that no emergent care is needed. Thus, the patient technically can not refuse urgent care since you have determined there is no need for it.

Read and understand your forms.

Again, no more volly debate…I am happy to have a discussion about the value or merits of college EMS squads, but on a separate discussion, away from this case review.

Volly? Why do you want to start a volly argument?

Even the majority of the volly systems have at least EMT-Bs.

My point is that a FR is not educated or trained well enough to be making medical decisions for what type of transport or getting refusals for medical emergencies regardless of whatever little liability disclaimer speech is used to get an RMA.

You list yourself as an emt-student or now EMT-B. How qualified are you to judge whether a system is providing adequate medical expertise?

The argument in EMS has been with people that have little medical knowledge making the decisions for who and what provides EMS. This includes the FD vs EMS debate. And now, we have members of the EMS community arguing for even a lower standard of care than EMT-B? Why bother advancing your education if you are already defending this standard of care? You see to think it is functioning fine as it is.

College students shouldn't be treated as second class citizens and should have access to at least an EMT-B in emergencies especially if the ambulance is to be dispatched later. That should just be the minimum requirement.

 

[BossyCow]

The reason we write r/o on the reports under the assessment portion is because we don't know and can't know what's wrong. Especially in an ABD pain case.

I've had cases I "Knew" were appendicitus that weren't and hot appendices that I guessed as kidney pain. I've seen appendicitus radiating to the left side, presenting as back pain and rebound tenderness showing up in a case of stomach flu/gastritis. Bellies are mysteries. Without the ultrasound, lab results and other miracles of modern medicine, belly issues cannot be diagnosed in the field... period.

 

[Veneficus]

The reason we write r/o on the reports under the assessment portion is because we don't know and can't know what's wrong. Especially in an ABD pain case.

I've had cases I "Knew" were appendicitus that weren't and hot appendices that I guessed as kidney pain. I've seen appendicitus radiating to the left side, presenting as back pain and rebound tenderness showing up in a case of stomach flu/gastritis. Bellies are mysteries. Without the ultrasound, lab results and other miracles of modern medicine, belly issues cannot be diagnosed in the field... period.

great post.

one of my profs likes to say that 75% of all medicine is in the abd. That's a lot of stuff.

 

[NebraskanPrincess]

This one time, I was convinced I was having a heart attack. It went away after an hour. The third time I had an attack I was working in the ER and bawled bravely for 1.5 hours from mid-chest pain until it went away. Had my gallbladder taken out precisely 5 days later.

I agree. The abdomen is weird - like a lot of the body. Things get more complicated with the possibility of referred pain.

ClarkEMS, good for you for wanting to learn In the future, while your partner is doing the assessment, you may remember to pay closer attention to what they're doing to pick up on details as well. Sometimes, if a person is in charge of strictly vitals, they will miss things the "scene commander" can pick up on by observing the patient. It takes a lot of communication and teamwork to provide full patient care.

The money issue is a tricky thing in our economy. It's going to get worse if the economy continues to get worse. I was working in the ER awhile ago and was stunned to see a purple, non-breathing baby fly through the front doors with frantic parents. They didn't want the ambulance to drive them because of the bills. Then again, it's not just the money that's complicating things. In emergencies, people freak out. They don't make the best decisions and they aren't rational. And even if it is a "minor" call, the stress of even having to dial 911 can be enormous for some people.

I'm not bold enough nor experienced enough to be able to tell you the "right thing" to have done in this situation. When the patient brings up money concerns to me, my standard line is, "my job is to worry about your health. These are your vitals, this is what could possibly be happening in your body, these are the risks of your not receiving more medical treatment. If money weren't an issue right now, what would your decision be?" I work for a private service that probably doesn't think I'm the greatest person in the world, but I didn't choose this job because I wanted some person at the top to get richer. And at the money I make, I know someone up there has got to be making some sort of good money

Ultimately, all we can do is be honest with our patients about what we observe/see/are trained and provide them their options. If they are conscious, alert, and oriented, it is not our jobs to make their decisions for them. Coercing someone to go with you is just as bad as convincing them not to. It's a double-edged sword.

The best you can do is do what you can with what you have. I have never been to the area you serve, don't know your protocols, don't know anything about your squad. I can tell you that I serve the Siberia of America where First Responders don't have the authority to make the treat/not treat decision in our rural areas. If they can't get EMTs to respond, our ALS unit has to make the trek out to the area even if to get a decline on our services. I'm glad that you're studying to be an EMT as I hope it will provide you with a rich base of knowledge that will help prepare you to serve the college students you do. Learn from experience and do it differently the next time - that's what will put you apart from many.

And heck yeah on the not treating College Students as second-class citizens. Now, can someone do a protest on my alma mater's campus and demand the cafeteria stop serving that poison? Ooo! And if you could stick up for we vegetarians whom they offered tomato sandwiches to EVERY day I'd be your fan!

 

[ClarkEMS]

Yeah, honestly, I don't know how cost became a factor in this discussion. The patient didn't choose a taxi over ambulance cause it was free, the ambulance is free too. No doubt that abd situations are tough I wasn't about to tell the patient that she had appendicitis or ectopic pregnancy or whatever, I never told her that I could diagnose her or that she had any of those things. I asked a few times if she wanted an ambulance, she refused I told her that she would have to take a taxi then which is policy and that is of no charge to her so she wouldn't be worried on that front, she signed a refusal with witnesses present, as she began to deteriorate, I sat down with her and explained that I felt it was safer to take an ambulance as she could be watched over and gotten to the hospital probably faster than a taxi which would most likely get stuck in a traffic. Mainly, I expressed that I wanted someone to be there if something happened which is what an ambulance could provide. She accepted, I radioed in, an ambulance arrived shortly thereafter, she was taken to the hospital, I happened to see her walking on campus this evening, I am sure she is fine. End of story.

I love learning, especially about what I can do to make things better on campus for our EMS service. Thanks for the advice!

 

[NebraskanPrincess]

Clark, I understand your frustration, but I hope you didn't perceive my suggestions as bashing you! I apologize if you did!

 

[ClarkEMS]

Clark, I understand your frustration, but I hope you didn't perceive my suggestions as bashing you! I apologize if you did!

Oh no you are fine! I appreciate what you wrote, I wrote that post before I saw yours. Thanks!

 

[triemal04]

seriously? he's a first responder, probably new to the field and at least he came here to learn what went wrong, cut him some slack. I agree it was wrong, and mistakes were made but it's a learning process, I was there in his shoes once, as I;m sure you were too, unless your one of those medics who thinks they never made a mistake, boy I know I have made some, but I;ve learned from each and every one, and thankfully no pt was harmed seriously in the process.

Doesn't matter. While I agree that newer people (and people who have been around for decades) will make mistakes, and that it's not always a bad thing (as long as they learn from the mistake and don't repeat it) that's not the only problem here.

If he's that inexperienced, why was he in charge by himself?
Why was an ambulance not dispatched right off the bat? And yes, his further posts make it pretty clear that he had to call for one AFTER contacting the pt.
Why was a BLS ambulance called for a female with abdominal pn?
Why is this inexperienced, uneducated and untrained person (sorry dude, but it's true, no offence meant) being put into a situation where he could be telling someone whether or not they need an ambulance or ER visit?

All these and more need to be answered. The problem goes beyond ClarkEMS and to his system, as it's being displayed here.

 

[medicdan]

Vent, lets agree to disagree. You brought up some interesting points, I have learned. Thank you.

 

[Jon]

Clark:

What conerns me is that you folks obtained a refusal without doing a thorough assessment of your patient - you said you didn't palpate the abdomen or get a complete set of vital signs until AFTER they signed the refusal.

A true RMA - "Refusal against Medical Advice" requires a FULL assessment, probably a call to a Command physician (under my local BLS and ALS protocols it does), and lots of documentation, as well as a good expination of the risks associated with refusal to the patient.

If you don't do this - you are doing your patients a disservice... and it might come back and bite you later.

 

[ClarkEMS]

Clark:

What conerns me is that you folks obtained a refusal without doing a thorough assessment of your patient - you said you didn't palpate the abdomen or get a complete set of vital signs until AFTER they signed the refusal.

A true RMA - "Refusal against Medical Advice" requires a FULL assessment, probably a call to a Command physician (under my local BLS and ALS protocols it does), and lots of documentation, as well as a good expination of the risks associated with refusal to the patient.

If you don't do this - you are doing your patients a disservice... and it might come back and bite you later.

Dually noted and I understand that. That is what concerned me too and this will most likely be brought up at our run review meeting with our medical director. The vitals were fine other than the fact that my partner didn't take repirations which I later took. This refusal is not a refusal of care it is a refusal to take an ambulance, in which case they are still forced to go to the hospital taxi. Next time I am going to make sure that repirations are taken and not overlooked. In the end though, due to a change in the patients condition an ambulance was called, we stayed with the patient taking more sets of vitals and watching her condition throughout this time. The ambulance took over care and she was sent to a hospital.

 

[VentMedic]

Next time I am going to make sure that repirations are taken and not overlooked. In the end though, due to a change in the patients condition an ambulance was called, we stayed with the patient taking more sets of vitals and watching her condition throughout this time. The ambulance took over care and she was sent to a hospital.

This is purely for educational purposes.

You have been focused on the respirations throughout this post. Was the patient having difficulty talking to you? Did you hear something suspicious in her breath sounds?

What would you expect the respiratory rate and quality to be for a young person in pain?

What in your findings would have taken you down a different path?

 

[rogersam5]

When I respond to a call that has any posibility of being serious an EA is called. I have had a few sign out, and not go to the hospital. But most go, when I tell them they should. I give them a good talk about what it could be and what could happen if they don't get it treated, I have had a few arm injurys that I convinced into going ot the hospital and they ended up a lot worse they the pt. thought they would be. If I am not sure how serious it is... I tell dispach to send me an EA, they Call WEMS, WEMS shows up and the Paramedics sort out what should happen, most of the time, the pt. goes for a ride with the Paramedics. I remeber one that just wanted a ride to the hospital down the street (literaly takes 5 min to get there) but we told them that it would be a better idea to take a ride in the ambulace, they agreed, WEMS brought them to the hospital...


If your the Clark I think you are... greetings from down the street.

 

[Emtgirl21]

A BLS ambulance transported her....thats the part I keep tripping on. An acute abdomen requires a paramedic, an IV, oxygen, monitor, and frequent vitals. An etopic can turn deadly quickly. Not to mention its just nice to have the option to give Zofran( or antimetic of your companys choice) vs having someone vomit all over your truck.

 

[Veneficus]

A BLS ambulance transported her....thats the part I keep tripping on. An acute abdomen requires a paramedic, an IV, oxygen, monitor, and frequent vitals. An etopic can turn deadly quickly. Not to mention its just nice to have the option to give Zofran( or antimetic of your companys choice) vs having someone vomit all over your truck.

Not trying to be smart or derogatory, but if suspected a ruptured ectopic pregnancy is a surgical emergency; there is nothing ALS is going to do for that. Fluid is not going to change outcome. If the BLS unit can get the pt to the hospital quicker, the BLS unit is the best option.

A pt. with a tubal pregnancy that has not ruptured can be treated medically in some cases. Nothing ALS does is going to make a difference there either

In either case vomit is of no concern.

 

[Emtgirl21]

So are you saying that you would not preform any ALS skills on said pt?