Another reason to DOCUMENT EVERYTHING

[NontradICUdoc]

From JEMS.com

EMS and the Law
with W. Ann Maggiore
03/30/2006
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A Lesson in ‘Negligence’

An RSI case involving MD assistance, documentation & protocol deviation

A recently published decision from the Northern District of Illinois federal district court has some important lessons to teach EMS personnel about documentation in the context of a rapid sequence induction (RSI). The opinion denied the EMS agency’s Motion for Summary Judgment, a motion usually filed by defendants in an attempt to achieve dismissal of a case prior to trial. For this type of motion, if the defendant can show that the facts of the case are not in dispute, they may be able to get the case dismissed as a matter of law.

In this case, the plaintiff’s estate sued the paramedics, the EMS agency, an urgent care physician and the hospital emergency department (ED) after an anaphylactic reaction resulted in the patient’s demise due to anoxic brain damage.

Case background
Shirley Johnson experienced an anaphylactic reaction after eating Chinese food. She had a known sensitivity to peanuts. Her husband, Richard, took her to an urgent care center, where he informed Dr. Drubka, the physician on duty, that she was having trouble breathing. Dr. Drubka found Mrs. Johnson in severe respiratory distress. The center called 9-1-1 immediately, and paramedics arrived about four minutes later to find the patient still in the passenger’s side of her car. They assisted in removing her from her vehicle and placed her into the ambulance. Dr. Drubka informed the paramedics that she needed to be intubated immediately and offered his assistance. They rejected his offer and initiated transport.

Johnson remained in the ambulance for 30 minutes. A patient care report that the paramedics generated at the conclusion of the call raised a number of issues, including the reason for two failed attempts to initiate an IV, the failure to place an oral airway, the amount of time that elapsed prior to intubation attempts and whether the final intubation attempt was successful. The parties also disputed whether the paramedics administered epinephrine to Johnson; despite the fact that both paramedics testified that they had done so, there was no documentation in their report of the drug being given.

The paramedics’ report indicated that they administered three separate dosages of Versed (a drug used for conscious sedation) because the patient’s jaw was clenched and they wanted to attempt intubation. The applicable protocols allowed administration of etomidate (a paralytic) if the patient was not sufficiently sedated to intubate within 60 seconds, but there was no evidence that the paramedics administered the drug. The paramedics testified that the reason for the unsuccessful intubation attempts was the patient’s clenched jaw, although the plaintiffs argued that the providers simply failed to comply with protocols. Finally, plaintiffs alleged that the third intubation attempt, which the paramedics testified was successful, was actually an esophageal intubation.

The ambulance arrived at the hospital about three minutes after the final intubation attempt. The paramedics testified that they had applied a capnography device and confirmed tube placement, and had also listened to the stomach and the lungs to reconfirm. Plaintiffs denied that the paramedics took these actions, pointing again to the patient report that made no mention of confirmation of endotracheal tube placement. The ED physician, Dr. Urgo, rechecked the tube and found that it was in the esophagus. He testified that the patient was pulseless and apneic on arrival, and that she was also cyanotic and had an extremely distended abdomen. He testified that it took him four attempts over 20–25 minutes before he was able to accomplish intubation.

The paramedics testified that the tube must have become displaced as Johnson was removed from the ambulance because her head was jostled as they moved the gurney. Plaintiffs argued that it took only about 60 seconds to move the patient into the ED, and that there was not enough time to account for her cyanosis and the abdominal distention.

Plaintiffs alleged that the paramedics’ conduct was “willful and wanton.” Under Illinois law, “willful and wanton” conduct is required before liability can be found against EMS providers. “Willful and wanton” conduct has been described as a hybrid between negligence and intentional behavior, and indicative of a reckless disregard for the safety of others. The line between negligence and “willful and wanton” conduct is, at best, a thin one.

A “battle of the experts” ensued in the briefing, with both sides filing affidavits of expert witnesses supporting their position. Frank Nagorka, an Illinois attorney and practicing paramedic, testified by affidavit that the paramedics fell below the standard of care when they failed to follow Dr. Drubka’s orders regarding intubation and refused his offer of assistance with securing the airway. Nagorka also said that they should have taken the patient into the urgent care center to stabilize her and obtain a secure airway prior to transport, and that EMS failed to follow their own RSI protocols. However, the EMS agency presented an affidavit from an Illinois physician who said the paramedics’ actions were appropriate within the scope of their training, and that their acts were not “willful and wanton.”

The court, after a lengthy discussion of the “willful and wanton” standard, noted that deviations from protocols have been found sufficient to clear that hurdle, although that may not happen under the facts of every case. The court denied the motion, and the case proceeded into litigation.

Discussion
This case is instructive in several areas. The physician on scene may have been able to provide additional assistance in securing the airway, and the paramedics may have allowed him to assist for the benefit of the patient. The paramedics’ documentation was deficient, and their defense was greatly hampered by the conflicts between their testimony and the report they generated immediately after the call. Finally, the issue of whether protocol violations rise to the level of “willful and wanton” behavior is one that courts will revisit in EMS litigation in states that provide immunity for all negligence with the exception of “willful and wanton” actions.


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[CatsandCradles]

Definantly interesting!

That was an enlightening read. You could use something like that in a medical ethics course. Classic case study event.

 

[jonb12997]

as I was taught from day one: "if you don't write it down, it didn't happen"...

 

[Jambi]

Write that stuff down...

From the story it sounds like a gross case of incompetence, but you all know how facts get twisted, turned, and rewritten during a case.

 

[docB]

There are some cases that you want to document much more carefully. A young, healthy person who dies suddenly needs to have a very well documented, legible chart. Not doing this, and not paying extra attention to the high liability cases, is suicide.

The applicable protocols allowed administration of etomidate (a paralytic) if the patient was not sufficiently sedated to intubate within 60 seconds, but there was no evidence that the paramedics administered the drug.

Even JEMS can get confused sometimes. Etomidate is not a paralytic.

You could use something like that in a medical ethics course. Classic case study event.

What ethical issue is brought up by this case?

 

[emtcsmith]

Do IL laws allow a non-Medical Command Physican to take such a role as preforming or helping in RSI? My understanding of the rules in my home state says that you don't have to do what a doctor says if they don't have Medical Command and when it doubt can call your command doc to resolve the situation.

This call sounds like alot of everything going wrong at the same time and whoever wrote the chart didn't help the situation. I have no doubt any good lawyer could make a good medic melt on the stand and unless we document everything we did and everything that happend this is going to happen.

The medics may have done everything they were supose to and a sloppy chart did them in or they may have done a good deal wrong and this sloppy chart the nail in the coffin.

I always reread my run sheets after I write them and ask myself if I'm someone else reading it does it pain the picture of the call and not something different then what happend.

 

[NontradICUdoc]

From what I understand, if a Dr. insists on giving the paramedics orders then the doctor must accompany the patient and sign all the charts as the attending. Besides, since the patient went to the urgent care center, if the paramedics would have allowed the doctor to intubate, it would be prudent to document this fact. The doctor is the senior medical authority on the scene and hence will be responsible for any procedure done by him.

If the paramedics would have allowed him to intubate and documented this fact then the lawsuit would not have happened. The patient was not properly treated because the medics did not want to take the suggestion of performing the intubation in the office. Why? Pride?

The medics did not follow ABC, they did not secure a patent airway and initiated transport without it. This sounds a lot like a case of pack em and take em. I know plenty of squads that do this and was even arguing with my driver who wanted a patient with a BP of 210/120 to walk to the stretcher on the other side of the house, I won.

We cannot allow the common sentiment that "we must free up the ambulance for the next call" to get in the way of proper patient care. The call will take as long as the call takes. Had the paramedics followed ABC and not TABC (Transport ABC) then the airway would have been secured, the patient's brain would not have been deprived of oxygen for so long and this case would not exist.

The ethical question is "Can and should a doctor step in at an accident scene?"

 

[rn29306]

The ethical question is "Can and should a doctor step in at an accident scene?"

Have seen this attempted and it wasn't pretty. EMS usually will not allow MDs to intervene. They told the MD to go back to his car and threatened to get the attention of the nearby officer if he didn't.

Have also seen EMS tell an anesthesiologist who was doing ventilation and family practice doc doing compressions at a ballpark one day to boot the both of them, actually did call the cops over, and the woman died from a delayed intubation - too bad it was in the esophagus when they finally got it.

Pride....

 

[a_ditchdoc]

I agree that the Paramedics were negligent in this case in respect to their care. However, that said, most paramedics are much more capable of treating airway problems and emergencies than are the on scene physicians. These physicians, often offering assistance with good intentions, frequently get in the way. Often the best thing they can do is to let the paramedics do their job.

With the agency I worked with, unless the patient had an ongoing relationship with the physician, EMS personnel were solely responsible for prehospital care unless medical control dictated otherwise. If the on scene physician wanted to assist, he was welcome to contact them via our radio or cell phones and sign a consent form indicating he was responsible for care and would accompany the patient to the hospital. This position is supported by the NC college of Emergency Physicians. If the physician was trained in emergency medicine, I would often follow their orders assuming it was within my scope of practice.

While the cases you pointed out show the paramedics botching something, I have more often seen the reverse...i.e. physicians trying time and time again to get an airway without success and refusing to let "subordinates" attempt intubation. On one scene involving a pediatric patient in a severe MVA, I arrived to find a physician trying to stop the bleeding of a minor scalp laceration. THe patient had been removed from his car seat and was being held up by a bystander while the physican dabbed a wound with guaze. When I suggested a different course of action, not only did he disagree, he cursed me for being so brazen. When I pointed out the obvious deficits in his treatment strategy, and the fact that the child would not die from the minor oozing of blood, but could have internal injuries and the possibility of being paralyzed from being moved about indiscriminately, he gave a final barrage and walked off. He was an ENT physician.

It is a difficult situation when a physician feels obligated to assist, and the paramedics feel obligated to provide what they feel is the best care for the patient. But being that most physicians are not trained in acute, life saving care, and have little daily experience with it, paramedics are more likely to be able to provide the standard of care required within their scope of practice.

 

[a_ditchdoc]

...the woman died from a delayed intubation .

If someone was ventilating this patient, and pumping on her chest, I would be very hesitant to say withot doubt that she died from delayed intubation. She probably died simply because her heart stopped. Most of these people die regardless of what you do.

 

[docB]

The ethical question is "Can and should a doctor step in at an accident scene?"

I don't know that that question is raised by the original scenario. In the case the patient has presented to and is under the care of the urgent care doctor when EMS was initiated. I don't think he was "stepping in." You could make more of an argument that EMS had no right to refuse his assistance because he was already in charge of the patient. You could also argue that he should have transferred the patient rather than just calling 911 but that's nitpicky.

As for the question of should docs stop at scenes the answer is that ethically they should if they can offer assistance that is not currently available and if they can do so without endangering themselves and becoming an additional patient. That said there is almost no instance in which a physician in the field can provide more than an ALS ambulance and crew. I only stop if there is no one on scene and that is so that I, as a highly trained medical person, can call 911.

 

[southerndoc]

I am not familiar with Illinois laws regarding physician intervention on scene, but I do know of a case where a physician was arrested for attempting to interfere with paramedic treatment of an accident victim.

My thoughts are that Illinois makes it tough for physicians to assist on scene, even if they are the referring physician.

 

[ShyRem]

There are several physicians I have spoken to that have stopped at scenes. None of them do that anymore - one was given a ticket by state patrol for parking his car on the shoulder while he offered care, one was sued by the victim's family (DOA on scene), another kicked off scene by EMS. Others have varying reasons similar to the afore-mentioned. As a paramedic, I was on scene once with a bad MVA. As I was trying to get stuff done in the car prior to extrication, I was forcibly moved and turned around by a man on scene:
him: "I'm here to help"
me: "Great - hand me a c-collar, will ya? it's that white thing over there..."
him: "Oh, no, I'm here to do patient care. I'm a physician."
me (not happy at this point and more than a bit skeptical): "what's your specialty?"
him: "I'm a podiatrist."
me: "well, if they have a foot injury, I'll call you. Now let me get to work."
At that point I ignored him. No, I'm not kidding about the above - still makes me laugh at the guy, and kinda pisses me off at the same time.

On the other hand, I've had urgent care docs want to stay with the patient and offer continued care. I got a release, noted in my trip sheet that the doc came along, called my medical control and let the two docs speak about the care given enroute. The patient benefitted, I was cleared, and the two docs agreed on what could occur en route; and I was grateful for the assistance. I'd do that again as long as the circumstances were not adversarial.

Now I'm going to med school. I'm not sure yet what my stance is on stopping to offer care, but I'm sure I'll be checking out state laws and my malpractice insurance small print.

 

[NontradICUdoc]

him: "Oh, no, I'm here to do patient care. I'm a physician."
me (not happy at this point and more than a bit skeptical): "what's your specialty?"
him: "I'm a podiatrist."
me: "well, if they have a foot injury, I'll call you. Now let me get to work."
At that point I ignored him. No, I'm not kidding about the above - still makes me laugh at the guy, and kinda pisses me off at the same time.

I had an incident like this as well. Except that I was called to the aid of a fellow marching band member who had a history of bronchial spasms. When I get there, I was trying to calm her down when some guy runs up to me and tells me that he is a doctor. I ask him what specialty. He tells me that he is a periodontist. His best advise to the patient was to "breath"

 

[viostorm]

I'll say this:

* I used to be a cocky paramedic, bashed physicians ... I mean, what were they thinking playing in my world!

* After 3/4 way through first year in medical school, physicians deserve nothing but the utmost respect. You can't believe what physicians learn, it makes all the paramedic stuff look trivial.

I was working an arrest and an OB-GYN tried to tell me how to intubate, and I said "look, she isn't have a baby ... back off"

Now I'm so embarassed at my behavior.

I didn't learn how to truly intubate until I cut a cadaver's neck apart, then I haven't missed a tube since. Med school taught me that not paramedic school.

As a whole, doctors know so much more then paramedics. That ENT doctor from the previous post was the likely top of his class ... higher then I will be in my class. Next time a paramedic criticizes a physician, just realize they have gone through so much more to get where they are. It is kind of like a CNA telling a paramedic how to pick a patient up off the floor.

I guess I'll just say this, just because a physician says something that isn't in your protocols, doesn't mean it is wrong. It may be that you are wrong, and just too ignorant to realize it.

Most of you all are physicians anyway so I'm not sure what I'm trying to say. I just hate it when paramedics talk like that.

 

[ShyRem]

I agree that physicians know more. Never argued that. However, I take offense when they treated me like that podiatrist did. I find many physicians realize what they know and what they don't (my own ob-gyn asked me how in the world I could remember all the ACLS stuff. I replied with how in the world he could remember all the female anatomy. We both laughed). I appreciate that. But I find it offensive when physicians are the 'know it all' types that really don't know it at all. Not even close. But then again, I don't like anyone who acts like that - whether they're EMT-Bs, paramedics, nurses, or physicians. *no one* knows it all - but let's all work as a team and not let egos get in the way. (i.e. "oh, no, I'm here for patient care" from the podiatrist when I'm halfway in the car holding pieces and parts. Moving the one who is holding those pieces and parts and has the best picture of what the heck is going on so far is not best for patient care.)

As for protocols - in the Denver metro protocols there is a specific protocol for physician assistance on scene to protect not only the paramedic, but the physician advisor and the physician on scene. I can only hope that other systems have the foresight to also have a protocol dealing with that situation.

And as for the CNA telling a medic how to pick up a patient - if that CNA is the patient's primary caregiver and knows something that can help, I'm all ears.

I hope when I'm in med school (or done with med school) that if I ever forget that what we know about medicine is a drop in the ocean and think I know it all that someone smacks me across the face and brings me back to reality.

 

[leviathan]

There are several physicians I have spoken to that have stopped at scenes. None of them do that anymore - one was given a ticket by state patrol for parking his car on the shoulder while he offered care, one was sued by the victim's family (DOA on scene), another kicked off scene by EMS. Others have varying reasons similar to the afore-mentioned. As a paramedic, I was on scene once with a bad MVA. As I was trying to get stuff done in the car prior to extrication, I was forcibly moved and turned around by a man on scene:
him: "I'm here to help"
me: "Great - hand me a c-collar, will ya? it's that white thing over there..."
him: "Oh, no, I'm here to do patient care. I'm a physician."
me (not happy at this point and more than a bit skeptical): "what's your specialty?"
him: "I'm a podiatrist."
me: "well, if they have a foot injury, I'll call you. Now let me get to work."
At that point I ignored him. No, I'm not kidding about the above - still makes me laugh at the guy, and kinda pisses me off at the same time.

On the other hand, I've had urgent care docs want to stay with the patient and offer continued care. I got a release, noted in my trip sheet that the doc came along, called my medical control and let the two docs speak about the care given enroute. The patient benefitted, I was cleared, and the two docs agreed on what could occur en route; and I was grateful for the assistance. I'd do that again as long as the circumstances were not adversarial.

Now I'm going to med school. I'm not sure yet what my stance is on stopping to offer care, but I'm sure I'll be checking out state laws and my malpractice insurance small print.

I had a case a while back of a post-ictal unconscious patient and an on-site physician tried to intervene. In the aftermath it caused an ordeal with the management at the site because I refused to allow him to take over. He was a family physician who had absolutely no equipment or supplies that would allow him to give higher care than myself, and for all I know he has not dealt with an emergency situation in 10 or 15 years. When I went for an OPA he asked me if I knew how to use it, and then started questioning me about only giving him 10 litre flow of O2 with a simple face mask and said the man needed 15 litres by non-rebreather (which isn't our protocol).

Sooo in my opinion, physicians should take over patients on scene IF they are able to provide a higher level of care than the current patient care providers. However, if they have no capability of providing higher care, then it is a bit of an insult to the people on scene to insist you take over. I don't argue this physician would have any trouble managing the patient, but when I'm already taking care of her just fine, he is basically insinuating that he doesn't trust me to watch her ABCs.

 

[a_ditchdoc]

* I used to be a cocky paramedic
* You can't believe what physicians learn, it makes all the paramedic stuff look trivial.

I have been a paramedic for 14 years. It is not cockiness, I know how to do my job. And you are right, doctors have to learn more than paramedics, much more. How much of that is emergency medicine?

Med school taught me that not paramedic school.

My first three years of medical school have also taught me a lot. But, I am going to go out on a limb and ask if you are a fairly new paramedic. Not knocking new medics, but I learned more about caring for critically ill patients, and intubation, in EMS than I have thus far in medical school.

That ENT doctor from the previous post was the likely top of his class ... higher then I will be in my class. Next time a paramedic criticizes a physician, just realize they have gone through so much more to get where they are.

I am sure he was near the top of his class, It di not change the fact that he could have killed the kid playing around with a damn scalp wound. Do you think he knew some magic "doctor stuff" about the scalp woulnd, or that he had ruled out other injuries? No. He was simply doing what most bystanders would have done...he focused on the most obvious...a scalp laceration. He was nice to try to help, but he should stick to ears, noses, and throats. If not, he should at least show some respect to other health professionals.

It may be that you are wrong, and just too ignorant to realize it.

I have been wrong many times, and will likely be in the future, this is not one of them. Perhaps as you get further along in your education you will realize that physicans, while knolwedgeable, are not the medical gods you imagine them to be.

 

[greytmedic]

First, my story about a physician at an urgent care facility. Called to the urgent care for about a 50 y/o male pt c/o chest pain. UOA at scene, pt laying in bed with nasal cannula at 2l/m, upon further inspection, oxygen bottle valve not turned on so actually no oxygen flowing at all (has happened to me several times at different urgent care facilities). Pt c/o crushing chest pain radiating to both arms, nausea, a some lightheadedness. Pt's wife at scene stated pt appeared slightly pale, pt also sweating. Pt hooked up to monitor showing sinus rhythm, slightly tachy. I talked to the doctor for report, while partner proceeded to do vitals. Doctor stated the pt was examined for the first time about 30 minutes ago, when the pt's condition had not changed with rest, decision was made to transfer pt to er. I asked if a 12 lead had already been performed(I saw the 12 lead sitting in the hall), doctor said no. Being that this is the most stereotypical case of chest pain I have ever seen, I decide I should probably go with the chest pain protocols. Partner gave me the vitals and nothing raised any flags, I can't remember exactly what they were. So, I ask the doctor if the pt has gotten any aspirin yet. The doctor says, "He took some motrin this morning for a headache, but he said they didn't really help." I shoot my partner a quizzical look and then ask, "No, I mean has he gotten any baby aspirin for the chest pain." To which the doctor replies, "Huh. No, that would probably be a good idea." Well, duh. I may not be a doctor yet, but it doesn't take a genius to follow ACLS protocols. Anyway, long story short, took the guy in, 12 lead done, pt having MI, pt went to cath lab, pt all better. At least the guy lived. After a couple of other different exchanges with urgent care doctors I have ammended one of my favorite sayings--What do you call a doctor who graduates Med school with a C? An urgent care facility doctor.

 

[greytmedic]

Secondly, I am a paramedic in Illinois. Out in the Northwest burbs of Chicago. I can not quote any of the actual state laws, but some of our system sop's will give you clue about the actions of the paramedics. First, our system states any qualified person who performs an intubation is responsible for that tube and must accompany the pt to the ER. This is geared more for ALS fire engines when a fire/medic may intubate before the ambulance arrives or while aiding the ambulance crew. It does also apply for providers at the scene. So, if the doctor was going to intubate, he would have had to go in the ambulance with the pt to the ER. If he couldn't go with, he shouldn't have been allowed to intubate. Secondly, in our system, if a doctor is on scene and wants to help he has to call medical control and discuss the pt with the ER doc and then go with in the ambulance. This is actually good for the pt, the doctors perhaps can discuss a little more detail about the pt's condition and it also keeps the doctor out the paramedics' hair so they can perform their treatments. I am not sure where this incident happened or any specific detail of the event or the system protocols where it happened, so I can only speculate on what really happened.

 

[docB]

This has kind of veered off into a discussion of dumb things doctors from weird specialties do on scene. These situations while alarmingly common don’t present any kind of a challenge. If you are a dumb doc from a weird specialty don’t do this. If you are a medic confronted with this toss the interference off scene, PD PRN. The real challenge is what to do when you have a legitimate doc who is offering help, possible one who is already treating the patient.

Here’s how I would break that down.

Docs:

Don’t stop at a scene that already has responders on it. If the scene does not have any response there pull over past the scene. Survey the scene and call 911. The most important thing you can tell them is where you are. Cross streets and mile markers are good. Next to the big tree and “directly under the Earth’s sun” (apologies to Chief Wiggum) are not helpful. The next most helpful things are number of vehicles, victims, severity, etc. The absolute last thing you should be doing is touching a patient.

If you do get involved in patient care you should be prepared to report to the EMS responders, identify yourself including showing a medical license and offer your help. If your help is declined you should ask if you can leave (law enforcement may want your info especially if you were a witness to the event) and then go. Docs frequently worry about the turning over to a lower level of care issue and the liability it causes. 99% of the time you don’t have anything above the ALS crew to offer anyway and I think that you can make a very convincing argument that a bare handed doc on the road side turning a pt over to a fully equipped ALS crew in an expeditious manner so that patient transport is not delayed after you offered what assistance you could will be a tough case to lose. If your assistance is accepted you must be prepared to accompany the patient on the ambulance, sign the paperwork and discuss the case with med command. If you are sending a patient from your office or urgent care the best thing you can do is have the pt’s chart ready to go with them. It would be much more appropriate for you to accompany this kind of patient than someone from a scene.

Medics: Know your protocols. If a physician’s offer of assistance must go through med com put them on the radio immediately. That keeps them out of your way while you get things going. It’s kind of like asking the Captain to check for any obstacles between the patient’s position and the rig. One thing to ask is what assistance over and above the protocols they are offering. They generally won’t know. Fortunately for any really crazy things they want to do the equipment won’t be available. The good thing is that the vast majority of the time they can not really do any harm. The one time when a bare handed doc could be a big help is having an OB to help with a crowning patient. They can do some manual maneuvers that can really help. Otherwise they are not that valuable.

 

[spo0kman]

Wow so many replies to be said

First I will address the case this topic is about. For those of you who insist that intubation needed to be the priority here, I have to completely disagree. Medics in general spend too much time doing the fun stuff and forget about the basics. This patient needed bagging and .5mg SubQ epi. For those of you who've not personally seen SubQ epi work in anaphylaxis, let me tell you its quick.

Secondly I was struck particularly by a post regarding an anesthesiologist who was told to stop bagging a patient, which according to the poster became the reason the patient died. Are you aware of how much liability is involved in letting a complete stranger perform ongoing patient care after arrival of EMS. What if these two doctors simply said they were doctors because they wanted the paper to write a story on them. I can just hear the lawyer now as I'm on the stand "So Firefighter Burnes, did you ever verify that these two gentlemen were physicians" "No Sir" "Doesn't your EMS protocol require that" "yes sir" (as far as the medics were concerned, these two doctors were complete strangers until they showed their MD liscence and agreed to take over care entirely)

As for the EMT going to med school, I completely respect your position and hope to be making the same move soon as well, however, don't forget where you came from. Just because as a medic you hadn't personally cut an airway apart doesn't mean you didn't know how to intubate. I'm sorry guys, but depending on the urgent care, there's no way in HELL i'm going to let these doctors screw around with my airway, simply put, I've got way more experience intubating than these docs two. I will admit, there are some urgent cares that are staffed by docs rotating between busy EDs and the urgent care, but I'd like to assume those docs would have the patient intubated prior to my arrival anyhow. The majority of the Urgent Cares in this area are staffed by urgent care docs, who specialize in suturing and general illness. No disrespect intended to them, I applaud their knowledge, but ego's aside, You can't honestly say that as your airway shuts down, if you had your choice, who would you rather have - The guy who cut an airway open during medical school 15 years ago and intubated a few patients during residency 10 years ago and hasn't done anything since, or the paramedic who hasn't cut an airway open, but successfully intubates someone about once a month for the last 6 years.

On top of that, while there are people like viostorm who have prehospital experience, there are also many many doctors who went straight from high school to college, then from college to med school, then to residency, etc. If you end up with a 2nd year family medicine resident with good intentions who fits the above critera, you really don't know whats going to happen.

I refuse to judge this run because simply put, I wasn't there. There is not one of us here who performs perfectly and documents perfectly every time. If you say you are, I'll call you a liar. I'm sorry if I come accross as an arrogant medic, but I think most of you pointing fingers and throwing accusations have never really been in this situation.

 

[spo0kman]

If you do get involved in patient care you should be prepared to report to the EMS responders, identify yourself including showing a medical license and offer your help. If your help is declined you should ask if you can leave (law enforcement may want your info especially if you were a witness to the event) and then go. Docs frequently worry about the turning over to a lower level of care issue and the liability it causes. 99% of the time you don’t have anything above the ALS crew to offer anyway and I think that you can make a very convincing argument that a bare handed doc on the road side turning a pt over to a fully equipped ALS crew in an expeditious manner so that patient transport is not delayed after you offered what assistance you could will be a tough case to lose. If your assistance is accepted you must be prepared to accompany the patient on the ambulance, sign the paperwork and discuss the case with med command. If you are sending a patient from your office or urgent care the best thing you can do is have the pt’s chart ready to go with them. It would be much more appropriate for you to accompany this kind of patient than someone from a scene.

I truly don't know for sure, but I'm under the impression in the above scenario that the doc would be covered under good samaritan laws, and abandonment wouldn't be an issue

Medics: Know your protocols. If a physician’s offer of assistance must go through med com put them on the radio immediately. That keeps them out of your way while you get things going. It’s kind of like asking the Captain to check for any obstacles between the patient’s position and the rig. One thing to ask is what assistance over and above the protocols they are offering. They generally won’t know. Fortunately for any really crazy things they want to do the equipment won’t be available. The good thing is that the vast majority of the time they can not really do any harm. The one time when a bare handed doc could be a big help is having an OB to help with a crowning patient. They can do some manual maneuvers that can really help. Otherwise they are not that valuable.

I will always listen to the report when I first arrive on scene. I can generally tell within the first 30 seconds if this information is valuable, or if the doc is out of his/her league, all over the place, not comfortable with acute patients, etc. Then I will quiety nod, and if the doc is really babbling I might politely move things along, because at that point, its not that I don't respect what the doc is saying, but I can figure out a lot more and lot faster by simply redoing my assessment, which I'll have to do anyways.

Fantastic post docb, you hit a lot of good points.

 

[docB]

I truly don't know for sure, but I'm under the impression in the above scenario that the doc would be covered under good samaritan laws, and abandonment wouldn't be an issue

This gets tricky. If the doc was seeing the patient then a relationship exists and the Good Sam is out the window. If the doc took any info and generated a bill or was initially planning on generating a bill then he is definitely not covered by the Good Sam. If the doc was seeing the patient there's always a concern that turning the patient over to a lower level of care is abandonment even though the only place an ALS rig is a lower level of care than a doctor's office in in the imagination of a plaintiff's attorney. That problem is the only reason that EMS agencies had policies about letting an unknown doc take over an ambulance. If they could get rid of the policy and avoid the whole mess they would. The whole abandonment issue is what keeps it alive.

 

[viostorm]

I appreciate everyone's comments, I have have enjoyed the discussion.

I'm sorry guys, but depending on the urgent care, there's no way in HELL i'm going to let these doctors screw around with my airway, simply put, I've got way more experience intubating than these docs two.

I would be careful with statements like *my* airway. A bit of para-god ego there?

there are also many many doctors who went straight from high school to college, then from college to med school, then to residency, etc. If you end up with a 2nd year family medicine resident with good intentions who fits the above critera, you really don't know whats going to happen.

Time and time again in multiple research studies it has been shown paramedics should not be intubating. I challenge you to find a single study that shows improved outcome from ground service paramedic intubation.

In European studies with physicians on ambulances there have been improved outcomes.

So I guess what I am saying is it is certainly not clear that any paramedic should be intubating anywhere. IMO paramedics just don't have the training necessary to perform the skill reliably and use it to improve outcome.

But, do FP physicians with skill atrophy? Not sure if it has been studied. One study I have always wanted to see is compare rural ED physicians versus paramedics for RSI.

If I had to judge the literature and my anecdotal evidence from my time as a paramedic, I would say if I am in need of intubation, let the physician do it and not the paramedic. This article is just another anecdotal example of what we know scientifically, paramedic RSI is a horrible idea.

If people would like to discuss this further, perhaps we can start a new thread .

 

[spo0kman]

*my* airway was taken out of context, I worded it poorly. I meant if it were me, I would rather have a paramedic intubate me than an urgent care doc with little to no intubation experience. I still maintain that you can read all about an airway in a book, you can even disect one, but intubating a dying patient is entirely different, I'm sure you will all agree to that.

Unfortunatly, I find those studies to be lacking somewhat. While I certainly wouldn't challenge an anesthesiologist who intubates 14 patients a day, I have to think I can intubate stronger and more reliably than a family practice doc who hasn't intubated a live patient in years if ever.

The majority of those studies seem to revolve around RSI also, which I view as skewed as well. There are paramedics that believe everything should be done on the scene, and wait for full sedation, intubation, and verification before even packaging the patient. We don't run that way. I believe fully that the second the decision is made that the patient needs transported (in the patient who needs intubated, we'll assume thats early on), every step from then on out should be moving yourselves one step closer to the back of the truck. I do believe in sedation intubation prehospital, in the right atmosphere, that is, on the way to the hospital while you are bagging, administer sedation, as soon as the patient is down, drop the tube.

I fear that the number of "bad tubes" found on admission to the ED are blamed on the medic innappropriately. I don't personally know any medics that would intubate the esophogus, and not realize it the entire trip. The only "bad tube" I had was one that dislodged while moving the patient out of the truck, into the ED, and onto the ED cart (somewhere in that process).

On a side note, there are also numerous studies that state ALS transport decreases survival rate in level 1 trauma patients. I think we can all realize how ubsurd that is and stipulate that we shouldn't go back to the days of throwing a patient in the back of a herse and drive like hell to the ED with no intervention. Again I go back to the problem of scene time, dispatch time, enroute time, all of these factors.

I am very confident in my airway skills, I am also confident that if I don't intubate a patient that I'm bagging, they will vomit, and probably aspirate, and die 5 days later of pneumonia. For those reasons I'd rather intubate

 

[southerndoc]

On a side note, there are also numerous studies that state ALS transport decreases survival rate in level 1 trauma patients. I think we can all realize how ubsurd that is and stipulate that we shouldn't go back to the days of throwing a patient in the back of a herse and drive like hell to the ED with no intervention. Again I go back to the problem of scene time, dispatch time, enroute time, all of these factors.

That is EXACTLY what we advocate. The only thing that saves a trauma patient is a trauma surgeon. Patients do not need IV's on-scene, enroute, or airway management onscene. It doesn't improve outcome, and actually worsens it. If you can do it on the way in, that's fine. What ends up happening is medics spend 10-20 minutes onscene establishing IV's when the patient needs blood and a surgeon and not IV's.

Just like how we advocate rapid transport without intervention for our serious trauma patients, we also advocate getting surgery involved early. This is why emergency physicians in private practice will often call in surgeons based on EMS patches. It's important to get surgery involved quickly.

Regarding the airway issue, I do not think paramedics would leave a tube in the esophagus on purpose. However, UNDETECTED esophageal intubations are a serious problem in the US. It doesn't matter if it was never detected when the patient was intubated esophageally by accident, or if it was never detected when it slipped out enroute. The problem still is the same: esophageal intubations that are unrecognized. This is why constant assessment and CO2 monitoring are needed in the field. One may argue with data that a lot of intubated patients have ET tubes that slip out when patients are removed from the ambulance, but consider this: patients are frequently moved in hospital from bed to bed, bed to CT, etc. and rarely have displacement of their ET tube; and a large portion of patients with unrecognized esophageal intubations in the field have very poor neurologic outcomes, suggesting the esophageal intubation occurred much earlier and wasn't simply a displacement while removing the patient from the ambulance. It's hard to argue with the Orlando data presented by Falk, et al.

Our paramedics must reassess breath sounds and CO2 monitoring after every patient movement. Although we do not require spinal immobilization, I do think it's an extra way to prevent ET dislodgement as this was supported by studies done by Matta et al in Maryland.

 

[greytmedic]

Our paramedics must reassess breath sounds and CO2 monitoring after every patient movement. Although we do not require spinal immobilization, I do think it's an extra way to prevent ET dislodgement as this was supported by studies done by Matta et al in Maryland.

I use a backboard and head-blocks everytime I put in an ET. Even if it non-traumatic in nature, the head gets strapped down just to keep it from moving. Usually, if it is a code, they get put on a backboard anyway for cpr, so it is easy to take an extra 10 seconds and strap down their head once the tube is in place, and confirmed in place. After the head is stapped down, I always recheck and confirm tube placement. Makes moving a pt real easy. If it is a RSI, we give them the drugs and get them on the backboard while we pre-ventilate them, doing both at once cuts down on wasted time.

I do think the old, "it must have dislodged while the pt was being moved" has become more of a scape-goat. That is why, in our system, we have to go through a class every year to be okayed to intubate in the system. The class is about 1/4 intubation skills, and 3/4 recognizing a misplaced tube. It is the utmost importance to constantly be re-evaluating the pt's condition during transport and not just put an ET and think everything is okay. So, the skill of intubaton is important, but recognizing when something is wrong is what keeps pt's airways patent.

 

[jbar]

edit

 

[jbar]

On a side note, there are also numerous studies that state ALS transport decreases survival rate in level 1 trauma patients. I think we can all realize how absurd that is and stipulate that we shouldn't go back to the days of throwing a patient in the back of a herse and drive like hell to the ED with no intervention. Again I go back to the problem of scene time, dispatch time, enroute time, all of these factors.

The reason to do studies is that they often find things that don't make intuitive sense. Just because we would expect that higher training on scene leads to better outcomes, if the data says BLS does better and the studies aren't flawed then the question is why ALS is "worse" for trauma.
Many medics have a tendency to stay on scene and do more because they are able to do more. There is a reason why there are places like New York City where trauma is run by EMTs. I work as an EMT on a ALS ambulance, and I have been on a number of calls where transporting a patient rather then sitting on scene and intubating saved a life. That being said, I have also been on calls where getting good IV access early saved lives because we were able to push fluids and the docs could give plasma and FFP quickly. I would agree that ALS is better for trauma IF the delivery of that advanced care doesn't increase scene time.

 

[a_ditchdoc]

I agree that the "tube may have been displaced when we were moving them" is too often used to cover up faulty intubations. Likewise, I have removed questionable tubes from other mediics and reintubated, all the while being questioned "I think it is in...". There is little room for pride in medicine. Sometimes you only get one chance not to kill someone. I would much rather bag someone than worry about the tube being in the esophagus.

So far as losing tubes due to patient movements, I agree that a cervical collar and board are incredibly useful. And while you note that tubes are rarely displced in the hospital, you also do not have eager first responders and firefighters in the hospital. When I started out in EMS, I had a few incidents that changed how I deal with the issue of tube security. We had firefighter, first responders ,and volunteer EMTs from another service that would respond with us. While they were often a godsend, some of the less experience personnel would get a bit too excited. In one incident, while unloading, I saw an ET tube pull out quite far. The firefighter (emt/first responder?) just pushed it back down. I am not quite sure he knew it was a problem to do this. In another, excited first responders took off running with the patient into the ED. In their eagerness, the bag came unhooked and I got left behind in the shuffle (Narrow ramp). I can't begin to tell you how it looks to wheel a patient into an ED, running, with no BVM around. It was quite embarrassing for me.

Now, when I am on scenes, I am a much better at maintaining the calm, which helps tremendously. Likewise, I stress the importance of the airway to the first responders and make it someones personal responsibility "You are keeping them alive with this tube, please don't allow it to move. If it does, let me know immediately." It seems to work. And finally, I have to say that since I whined enough to get the department to buy commercial tube holders years ago, I have never had a probelm with a tube being displaced or even moved. As a department, I also think we have not lost any due to movement.

I have read a few of the studies concerning the lack of benefit for ALS ambulances. I have to say I am disappointed with the results. We lke to think that we are doing good things for our patients, that we really make a difference. All of my experiences tell me that I have saved people that otherwise would not have lived. I believe this whole heartedly. On the other hand, perhaps it is not balanced with the unintentional harm I caused. When I started out in EMS, aggressive fluid resuscitation was the rule. I have watched many of my patients bleed a clear, pink fluid on the floor of my ambulance, something that I now know is incompatable with life.

Something I would like to see addressed in a study is the ALS vs BLS survival of patients transferred to community hospitals without a surgeon, those patients that have to be transferred to a trauma center miles away. EMS, as a profession, is resistant to change. While we want to best for our patients, I also think we find ourselves threatened by studies that may not prove us to be of any benefit. EMS needs to be involved in more studies, not studies coming from within the hospital. Perhaps then we can institute non-biased evidence based medical protocols that benefit our patients, even on paper.

 

[niko327]

I agree that the "tube may have been displaced when we were moving them" is too often used to cover up faulty intubations. Likewise, I have removed questionable tubes from other mediics and reintubated, all the while being questioned "I think it is in...". There is little room for pride in medicine. Sometimes you only get one chance not to kill someone. I would much rather bag someone than worry about the tube being in the esophagus.

So far as losing tubes due to patient movements, I agree that a cervical collar and board are incredibly useful. And while you note that tubes are rarely displced in the hospital, you also do not have eager first responders and firefighters in the hospital. When I started out in EMS, I had a few incidents that changed how I deal with the issue of tube security. We had firefighter, first responders ,and volunteer EMTs from another service that would respond with us. While they were often a godsend, some of the less experience personnel would get a bit too excited. In one incident, while unloading, I saw an ET tube pull out quite far. The firefighter (emt/first responder?) just pushed it back down. I am not quite sure he knew it was a problem to do this. In another, excited first responders took off running with the patient into the ED. In their eagerness, the bag came unhooked and I got left behind in the shuffle (Narrow ramp). I can't begin to tell you how it looks to wheel a patient into an ED, running, with no BVM around. It was quite embarrassing for me.

Now, when I am on scenes, I am a much better at maintaining the calm, which helps tremendously. Likewise, I stress the importance of the airway to the first responders and make it someones personal responsibility "You are keeping them alive with this tube, please don't allow it to move. If it does, let me know immediately." It seems to work. And finally, I have to say that since I whined enough to get the department to buy commercial tube holders years ago, I have never had a probelm with a tube being displaced or even moved. As a department, I also think we have not lost any due to movement.

I have read a few of the studies concerning the lack of benefit for ALS ambulances. I have to say I am disappointed with the results. We lke to think that we are doing good things for our patients, that we really make a difference. All of my experiences tell me that I have saved people that otherwise would not have lived. I believe this whole heartedly. On the other hand, perhaps it is not balanced with the unintentional harm I caused. When I started out in EMS, aggressive fluid resuscitation was the rule. I have watched many of my patients bleed a clear, pink fluid on the floor of my ambulance, something that I now know is incompatable with life.

Something I would like to see addressed in a study is the ALS vs BLS survival of patients transferred to community hospitals without a surgeon, those patients that have to be transferred to a trauma center miles away. EMS, as a profession, is resistant to change. While we want to best for our patients, I also think we find ourselves threatened by studies that may not prove us to be of any benefit. EMS needs to be involved in more studies, not studies coming from within the hospital. Perhaps then we can institute non-biased evidence based medical protocols that benefit our patients, even on paper.

You know, I think a_ditchdoc hit the nail on the head when he talked about overexcited rescuers and the need to maintain the calm. I think that this is probably one of the most important things a paramedic can do in terms of running a good call with more than 2 rescuers vs a clusterfcuk. This is something that I learned early on in the job, no matter what you've got, you always have to have your game face on. When they see you nervous or excitable, they respond in a similar but amplified manner. Once the ball gets rolling to crazy town, its very difficult to break the ensuing cycle of dysfunction. This is not just true in the field, I've seen the same crap happen in the hospital. This is a seriously overlooked dynamic that needs to be studied.

I've noticed that people will look to the highest trained provider in an emergency or crisis situation, and will exactly emulate their stressful state. Stress causes tunnel vision, destroys concentration (ie simple drug calculation becomes linear algebra), impairs good judgement, not to mention that fine motor control goes out the window, and causes accidents to happen when people don't take precautions. Good outcomes are rare in clusterfcuks.

 

[docB]

Good outcomes are rare in clusterfcuks.

Quote of the month!

 

[spo0kman]

I coudln't agree more with rapid scene times. As an EMS instructor when doing continuing education I am sometimes encountered by medics who disagree whole heartedly with the theory of "once the decision is made to transport, every move from then on out should get the one step closer to the ER"

I think the real issue here is medics who were forced to medic schools to be on a fire department. These guys and gals often don't want to be medics, and don't take the initiative to get better. I think more training may be in order, but better screening is just as important.

Are there medics that tube and forget it, sure probably. I do put a lot of faith into the guys I work with, however, that if there was an esophogeal intubation, they would know it. I have personally never once said "I think its in". Its either in or its not, and I know this buy visualization of the cords, CO2 and pulse ox, and lung sounds.

I hope I don't come accross as an over zealous medic who spends hours on scene. I absolutely believe in quick scene times. That being said, I absolutely advocate the treatments we can do enroute and have seen with my own eyes those treatments make a huge difference.

 

[NontradICUdoc]

As a nonmedic EMT, my first concern to is to get the patient the proper medical care that he or she needs. To me, it is very important to get a proper assessment. I have been on scenes where the EMT is so gung ho to get to the next call that they will actually do things fast and of course wrong. For example, when BLS gets called out to a fallen and can't get up. Some people I have ridden with had gone so fast to the scene, yanked the patient up, shoved them into bed and had them sign the refusal to ensure that the rig is available for another call.

One big problem in BLS is that everyone wants to the blood trauma or the cardiac arrest. They want the glory and the ability to say "I was there".

While I am not an instructor, I have been around the block a few times and I am a trainer on my department. What they do not stress in EMT class that I believe they should is how to properly approach a patient when you come to the scene. I have drilled into the head of new people on my squad that the first thing you say when you get to a scene is, Hello. Get the patient calm knowing that help has arrived.

 

[a_ditchdoc]

Its either in or its not, and I know this buy visualization of the cords, CO2 and pulse ox, and lung sounds.

I may be dating myself but, I was a medic before these techologies were available in the prehospital environment. Well...not the stethoscope of course....

 

[jbar]

I may be dating myself but, I was a medic before these techologies were available in the prehospital environment. Well...not the stethoscope of course....

daddy, tell me about the MAST pants days. What's Bertyllium?

 

[docB]

daddy, tell me about the MAST pants days. What's Bertyllium?

Yeah, you young wippersnappers with all your fancy gear. Back in my day all we needed was a strong team of horses to pull the ambulance and I didn't hear anyone complaining.

 

[leviathan]

Yeah, you young wippersnappers with all your fancy gear. Back in my day all we needed was a strong team of horses to pull the ambulance and I didn't hear anyone complaining.

Did you have an ample supply of leeches on the rig?

 

[docB]

Did you have an ample supply of leeches on the rig?

Well sure. Without enough leeches your laudenum and mercury just aren't going to be effective. I will admit that between the jars of leeches and the poultices laced with horse manure and rag weed the back of the rig wasn't a pleasent place on a hot, humid day. See, you kids today just don't appreciate how good you've got it tansarnit!

 

[a_ditchdoc]

daddy, tell me about the MAST pants days. What's Bertyllium?

Oh my...but do I have stories to tell....

 

[ShyRem]

a_ditch... um... I remember those days, too. Oh, my.

Remember when glove use became mandatory? yup. BIIIIIIG screams from the old-timers around that time. Until HIV became so prevalent.

and bicarb was a first-line cardiac drug? Calcium?

The days before opticom.

Yeah..... I remember those days too.... Damn. I don't *feel* that old!

 

[beanbean]

Interesting dicussion in this thread...and I am another old-timer from the Age Before Gloves! Remember the old wooden short boards before there were KEDS and the two piece Philly collars before the StiffNecks....and sandbags! as neck stabilzers which of course could also be used to splint a flail chest!

 

[jbar]

Actually, even though I'm a new schooler I've used some old school stuff. When I started with ski patrol we were using the Thomas Iron for femur fractures. It was invented in WWI, basically two long metal poles connected via a half horse collar. You made a ankle hitch with some crevats, pulled traction with two more crevates and tied em off when you had pulled enough. (side note, before the thomas iron the mortality rate amongst British troops from femur fx was about 80%, after it's introdiction it dropped to something less than 10%, the inventor ended up getting knighted over it)

 

[ShyRem]

Ah, yes. Back when they taught you how to do c-spine with a blanket. (I can actually do that still to this day.) And I still use a cravat when some ***** before me doesn't put the ankle strap back (or when fire tosses 'em GOKW).

BTW: I still use IV bags on MCIs for c-spine and flail chest. Works like a charm and there's plenty of 'em.

Anyone remember a course that used to be taught (I haven't seen it in about 10 years): "Hands on, Hands only"? You could only use what you had on you. Really awesome course.

 

[a_ditchdoc]

I don't suppose anyone remembers C-Med???

 

[jonb12997]

mast pants... lemme see, aren't those the things that are in the container used to sit on to look out between the two front seats on the way home from ambulance calls? I didn't know they had any other use! :-D

 

[a_ditchdoc]

mast pants... lemme see, aren't those the things that are in the container used to sit on to look out between the two front seats on the way home from ambulance calls? I didn't know they had any other use! :-D

Man, I have blown them things up more times than I can count. We even learned to put them on in the dark. I finally figured out how to blow them up with oxygen tubing and a 3.5 mm ET tube adapter because I didn't like putting my mouth so close to someone covered in blood (plus I saw where them pants had been). Despite the current trend of disuse, I have seen them work wonderfully. It is too bad I was inadvertanly doing these patients in....

 

[MacGyver]

Back to the original case.....

why on earth is the ER doc and urgent care doc being sued here?

they didnt do anything wrong

i'm so sick of punkass lawyers.... of course they got sued because its much more lucrative to sue the hospital/doctors rather than the paramedics.

What a freaking joke