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Discussion in 'Emergency Medicine' started by EMmedic, Dec 5, 2008.
I bet those medics are unemployed. Brief synopsis for those who don't want to watch: EMS called to home of previously well middle aged african american man who has acute dyspnea - they apparently tell the family it is reflux and do not transport and he drops dead.
I will say that in my region of the country EMS knows that patients who call and don't want to transport are a BIG liability and actively try to get the patient to come to the ED. If they won't come they usually call and talk to us.
I think it's a big lesson to not work outside of your expertise. Enough mistakes are made even with outstanding knowledge of practiced physicians and nurses with the aid of labs and imaging. EMS workers are wonderful and experts in what they do, but deciding that a 40 year old man is not having an MI and should instead go buy some pepto bismal??? Not their place at all.
I think I'll go treat my Grandpa-in-laws prostate cancer now. Oh wait, I'm not a urologist nor an oncologist.
Reminds me of the time I followed protocol and called in an ALS squad for a 50 year old woman with crushing chest pain nontender to palpation and radiating to the left arm and accompanied by SOB and diaphoresis. On their arrival, the patient felt better, with less pain and no SOB while getting hit with 15 L oxygen. A quick check of the monitor looked normal. They dismissed it as a panic attack, and talked over me as I tried to persuade the lady to head over to the hospital just a few minutes away. No transport.
That was one of the longest "cancelled by EMS" narratives I've ever written. The variability in EMS quality can be terrifying.
What I can imagine happened could fall into the below:
-burnt out urban providers who didn't care enough to transport someone
-tired urban providers who simply missed an actually sick patient after 8 bs patients
But I dare not monday morning quarterback the actions of any provider based on a news story. Nobody hear has the actual chart, or was actually there so lets not forget that.
True, but if we can take his wife's account as true that he had:
chest pain w/ shortness of breath
And you tell the guy to stay home and take antacids?
Forget about what his ECG said (if one was done), what his risk factors were, what his medical history was...paramedics shouldn't be diagnosing problems, case in point.
I wish we had more info...was the patient actively having this pain when they arrived? Was it relieved by anything, if anything was even given? It's hard to make a judgement with so many missing pieces, but no matter how "un-sick" someone looks, if they were having the symptoms the patient in this story was having, I would never mess around or hesitate to bring them in. I just wish we could see the EMS report to see what their thought process was. Either they were being negligent and lazy, or something wasn't obvious to them.
Sadly, I've seen EMS talk people out of transport. Most of the time they really didn't need it, but other times it was the opposite.
I'm a little amazed that this happened only a few years after they killed David Rosenbaum in a high-profile incident that supposedly led to sweeping reforms. They also have had remarkable turnover of medical directors (at one point six in a seven year period) and if memory serves, a scandal involving issuance of fraudulent EMT cards. It seems like DCFD has become the King/Drew of EMS.
Stories like this make me question my "why can't our rescue squads no-transport these people?" I forget how slippery of a slope it can be.
For every 4 year old with flea bites brought in, a 40 year old with a fatal MI isn't. I guess I can see and dispo the flea bite in less time than the family spends at the wake.
Currently, at our facility, to No Transport someone requires a radio call to the MD.
Having worked as an ED attending in DC for 2+ years, I can tell you, that though I love the paramedics and firefighters themselves (they are very nice people), the quality of their care is dubious. I was an EMT in VA (Basic), did residency in Tampa, and now am in Wisconsin, and I can tell you that without a doubt the DC EMS system is definitely subpar. I won't give examples, but it doesn't surprise me. I am glad to be in an area with great EMS!
While we obviously don't have the entire story...I really don't think there is any reasonable excuse for this. I hate this kind of thing because it makes EMS look terrible to the public and to the medical community. It only takes a few bad apples to ruin it for everyone else.
I'm sure this had something to do with the medics being burnt-out, tired, and looking for a reason not to do their jobs. Unfortunately I have seen it way too many times. They don't want to be in EMS anymore but have nothing else to fall back on so they stay on the job.
How can we say that? Maybe the paramedics truly thought the patient was hyperventilating? Perhaps he didn't look as bad as the media implies he did.
We all act like this doesn't happen in our ER's. There have been several high profile deaths of people who were ignored by emergency staff. The incident at MLK in Los Angeles, a psych patient in New York, and the list goes on.
This can happen to anyone. This could have easily been a triage nurse dismissing the patient's complaints and having him die in a waiting room or a doc dismissing his complaints and discharging him home.
As a former EMT, I have to respectfully disagree with you, and point out a major difference between the examples you give and the medics in this case. The nurse and the doctor in your examples made the wrong decision, but made a decision within their scope of training and practice (eg a doctor is trained to discharge patients, a triage nurse is trained to triage patients).
Medics do not have antacids within their scope of practice, so this decision was not just the wrong decision, it was beyond their scope and therefore they shouldn't have been making a decision like this at all. The outcome is not the issue here, it is the thought process that led up to it that makes this intolerable.
You're absolutely right...this could have been something an EP him/herself discharged without a second thought. The problem is we will never know whether it was the lack of training from the EMS crew, or if it was just a very, very unfortunate presentation that anyone would have missed. Until doctors are manning ambulances, we should assume that EMS personnel do not have the proper education to refuse transport and should not have the right to refuse.
The service I work for has a policy that prevents us from refusing transport, but that doesn't mean we don't convince some patients to sign our refusal form under certain circumstances. At the end of our discussion, if they still want to go, then we cannot refuse to transport. From what I understand, this patient WANTED to go to the hospital even after they had assessed him, and they still refused. That is unacceptable and negligent.
I suspect that the media put a negative spin on this story, and we dont know what happened exactly.
I also agree that this sort of thing can happen to anyone, and I'm not sure that they acted outside their scope.
We dont know how the patient presented. However, I would think that any medic who had a 40 year old patient who was had CP, SOB, was cool pale, diaphoretic, VS out of range, and had ST elevations on the monitor, would bring that patient to the ED. And so, I would assume that this patient didn't present this way.
I'd also like to know what sort of refusal protocols they had in place. I would also assume that they couldnt just pack their bags and leave the patient there without calling the MD or at least the Tour Chief.
And who reccomends Pepto to anyone, anyway?????
As a former paramedic, we had treat and release protocols in place where I worked. Many places also have these, although it doesn't appear DC EMS has these in place yet.
EMS varies significantly from state to state and even within states. Although not acceptable where you worked, the diagnosis of conditions and appropriate treatment of conditions outside of protocol was allowed and even facilitated by utilization of non-standard protocols. For instance, we didn't have a specific nausea and vomiting protocol, but our protocol for metoclopramide and droperidol drug usage allowed us to use it for nausea and vomiting without consulting with a physician.
As far as we know, the patient may have signed an AMA form.
A wrong decision was made. My point was that it could have happened to anyone of us, and we shouldn't be so hard on these guys without knowing all the facts. For all we know, the patient could have refused to go to the hospital despite the family wanting him to go.
ha!! I KNEW he was going to say that
I completely agree. Where I was a medic, we had a space on the chart where we documented our (presumptive) diagnosis. Evidently these medics made a presumptive Dx of GERD or gastritis, and that may not be outside of their scope of practice.
Remember, we are hearing an obviously incorrect Dx as reported by an upset family member. We dont know exactly what the medics told the patient.
Also, another place where I worked for a short time, we had protocols similar to what SouthernDoc had... treatment of non-protocol conditions, and off-protocol indications for the drugs we carried.
Yes, I admit it, I'm an EMS junky. My NREMT-P certification is still current and valid.