question about chocking

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reedman

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suppose a 65 yo man collapses at a party and some bystander initiates chest compressions while ems is called. 10 minutes later ems arrives and attaches a defibrillator, which reads something that looks like vfib, and applies one shock. then they start giving drugs and stuff...

suppose this man choked? what is the likelihood that he would be in vfib after ten minutes of chest compressions without a single breath? then ems didn't even think to asses the airway because the defibrillator started beeping?


on new years eve i was at an event where this happened. there was an announcement that a man had collapsed. the manager was asking if a doctor was in the crowd. so one lady said she is an EMT. i follow her over to the guy, where she starts looking for a pulse. she finds none, but i reached down and felt a strong radial pulse right before she started chest compressions. i voiced my findings only to have her shake her head at me because she was convinced he was having agonal gasps and that meant heart attack. after repeating my self several times, i suggested that i give him a breath to see if his airway was open, but she said "we don't do it like that anymore". after about ten minutes EMS arrives, i tell them that he had a pulse earlier but then the defibrillator beeps and the rest is history... i do think i saw vfib on the screen.

this scenario keeps playing over in my head. i really hope that guy had a stroke or PE because i keep thinking that he choked and i didn't take control. any thoughts on this?

edit: i forgot to mention that i asked if anyone had tried the heimlich when i first arrived, but only got blank looks.
 
1. It is possible to have V-Fib after approximately 10 mins of nothing but chest compressions. I have seen it a few times and even gotten one or two back.

2. EMT should've checked Airway, Breathing, Circulation to the best of their ability (see caveat below) without question.

>>>Caveat<<<
In theory, the first responder gives rescue breaths if indicated. This means direct mouth-to-mouth contact or via barrier. In the real world, it doesn't happen. The only time I have ever seen it happen is between family members. That being said, I can guarantee you that if I stumble across an arrest while not on duty and sans a BVM, they are only getting chest compressions.

3. If said patient was indeed choking AND unresponsive then chest compressions are indicated. Consider direct visualization to locate any FBO and while not recommended, finger sweeps can be helpful. If EMS gets there, the SLAT maneuver is fairly nifty and does work. Don't forget to keep suction handy.

4. If all else fails, while the crowd is distracted go their belongings and hope to score a few hundred bucks for your "Medical School Debt" fund.
 
Welcome to the prehospital environment. Are you familiar with the term "SNAFU"?
 
I was hoping this thread was about "cocking." Especially after hearing a recent rectal foreign body story that involved expanding bathroom cocking. I am very disappointed to find out that "chocking" was a typo for choking instead 🙁
 
65 yo "collapse" does not sound like a choking episode. Adequate bystander hx being the most important aspect of the case.

65 yo sudden "collapse" sounds like cardiac dysrhythmia or other sudden events (e.g. PE, AAA rupture, Spontaneous SAH). People don't typically have a sudden collapse from hypoxia or sudden and complete anoxia. That tends be progressive and would likely be confirmed by bystanders.

RAGE
 
EMRAGE said:
65 yo "collapse" does not sound like a choking episode. Adequate bystander hx being the most important aspect of the case.

65 yo sudden "collapse" sounds like cardiac dysrhythmia or other sudden events (e.g. PE, AAA rupture, Spontaneous SAH). People don't typically have a sudden collapse from hypoxia or sudden and complete anoxia. That tends be progressive and would likely be confirmed by bystanders.

RAGE
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what you are saying makes sense except for one detail: i felt a pulse in his radial artery. i can't figure out why she needed to start compressions right away after i mentioned his pulse. if someone is unresponsive and they have a pulse wouldn't you need to look at air way problems and respiratory failure?
 
reedman said:
what you are saying makes sense except for one detail: i felt a pulse in his radial artery. i can't figure out why she needed to start compressions right away after i mentioned his pulse. if someone is unresponsive and they have a pulse wouldn't you need to look at air way problems and respiratory failure?
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The patient did not have a pulse for the first responder, the EMT. She feels no pulse, so she does the right thing and initiate chest compressions immediately per current ACLS guidelines (protocols have changed to CPR only for first responder except in certain scenarios). I'm not sure what you felt exactly, could have been the patient was extremely bradycardic, you felt your own pulse (transmitted from your fingers), or something else was going on. Regardless, chest compressions are priority one in this situation.

Nothing about the incident particularly screams choking to death, and there is a big lack of bystander history "the guy was choking and then collapsed". Additionally, if it makes you feel any better, when the rest of EMS got there, if there was an acute airway obstruction, then it would have been impossible to bag the guy. So in the end, whether you felt a pulse was there or not, I'm not sure the scenario really should've gone any differently.

As an aside, unless you're ACLS trained and the EMT isn't (and from her remark of "we don't do it like that anymore" it sounds like she's up to date for 2010)), I'd step aside and not feel bad at all. They have their training for a reason. It's different than our training and better suited to such situations.
 
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reedman said:
suppose a 65 yo man collapses at a party and some bystander initiates chest compressions while ems is called. 10 minutes later ems arrives and attaches a defibrillator, which reads something that looks like vfib, and applies one shock. then they start giving drugs and stuff...

suppose this man choked? what is the likelihood that he would be in vfib after ten minutes of chest compressions without a single breath? then ems didn't even think to asses the airway because the defibrillator started beeping?


on new years eve i was at an event where this happened. there was an announcement that a man had collapsed. the manager was asking if a doctor was in the crowd. so one lady said she is an EMT. i follow her over to the guy, where she starts looking for a pulse. she finds none, but i reached down and felt a strong radial pulse right before she started chest compressions. i voiced my findings only to have her shake her head at me because she was convinced he was having agonal gasps and that meant heart attack. after repeating my self several times, i suggested that i give him a breath to see if his airway was open, but she said "we don't do it like that anymore". after about ten minutes EMS arrives, i tell them that he had a pulse earlier but then the defibrillator beeps and the rest is history... i do think i saw vfib on the screen.

this scenario keeps playing over in my head. i really hope that guy had a stroke or PE because i keep thinking that he choked and i didn't take control. any thoughts on this?

edit: i forgot to mention that i asked if anyone had tried the heimlich when i first arrived, but only got blank looks.
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When a 65 year old man collapses suddenly, the overwhelming likelihood is that it's a cardiopulmonary arrest (dysrhythmia/MI/PE), and NOT a choking arrest, unless there is some other history to indicate a primary AIRWAY arrest. This is completely reversed in children, however. Always remember that. Also, if you are a med student, its most appropriate that you let the EMT do his/her job and you stay out of the way and learn, as opposed to interfering with them doing what they are intended to do. If you are an attending, or more experienced resident and you feel confident taking over, you certainly can do that. But just like one of the other posters said, the prehospital environment is very different from the hospital/ED environment. Other than possibly getting an airway that EMS had trouble with, you're not going to be able to add much other that oversee the fact that they are following ACLS protocols and step in if they make a noteable error. As you are finding out, crisis and code situations rarely play out identically according to any protocol as much we'd like them to. The only environment more chaotic and difficult to work in than the ED, is prehospital.
 
reedman said:
i suggested that i give him a breath to see if his airway was open, but she said "we don't do it like that anymore".
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I was taught in ACLS that chest compressions are indicated in an unresponsive choking person because they might help with expelling the object, if that makes you feel better.
Just as a side note, anytime that you're in a code as a med student, I think the most useful thing you can do is offer to help with the chest compressions. I don't know if you've had the chance to do compressions yet but it is very exhausting work, and I hope the poor EMT wasn't doing it all by herself for 10 minutes.
The place where I did my internship at had a policy during codes that the person doing chest compressions *must* switch with someone else after two minutes because they felt that after that point the person doing compressions gets too tired to be really effective. If there are others around who could be helping with chest compressions, don't try to be the hero who keeps going as long as possible, because if you can't push hard enough then you're not helping the patient.
 
Birdstrike said:
When a 65 year old man collapses suddenly, the overwhelming likelihood is that it's a cardiopulmonary arrest (dysrhythmia/MI/PE), and NOT a choking arrest, unless there is some other history to indicate a primary AIRWAY arrest. This is completely reversed in children, however. Always remember that...
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This latter statement is incorrect. A witnessed, sudden collapse of a child of any age is a cardiac arrest, until proven otherwise (I have seen kids come in neurologically devastated because EMS providers and others earlier in the pipeline to the hospital, stupidly failed to remember this). If a child has a sudden witnessed collapse, priority is getting electricity available ASAP while utilizing the remaining PALS protocol. If a child is found unresponsive (unwitnessed), then yes, the likeliest course of events was pulmonary-->cardiac arrest (if they are found pulseless, unless there is a history to suggest otherwise. This is the reverse from the adult presumptions where it is most likely to be a cardiac arrest causing an unwitnessed or witnessed collapse).
 
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reedman said:
suppose a 65 yo man collapses at a party and some bystander initiates chest compressions while ems is called. 10 minutes later ems arrives and attaches a defibrillator, which reads something that looks like vfib, and applies one shock. then they start giving drugs and stuff...

suppose this man choked? what is the likelihood that he would be in vfib after ten minutes of chest compressions without a single breath? then ems didn't even think to asses the airway because the defibrillator started beeping?


on new years eve i was at an event where this happened. there was an announcement that a man had collapsed. the manager was asking if a doctor was in the crowd. so one lady said she is an EMT. i follow her over to the guy, where she starts looking for a pulse. she finds none, but i reached down and felt a strong radial pulse right before she started chest compressions. i voiced my findings only to have her shake her head at me because she was convinced he was having agonal gasps and that meant heart attack. after repeating my self several times, i suggested that i give him a breath to see if his airway was open, but she said "we don't do it like that anymore". after about ten minutes EMS arrives, i tell them that he had a pulse earlier but then the defibrillator beeps and the rest is history... i do think i saw vfib on the screen.

this scenario keeps playing over in my head. i really hope that guy had a stroke or PE because i keep thinking that he choked and i didn't take control. any thoughts on this?

edit: i forgot to mention that i asked if anyone had tried the heimlich when i first arrived, but only got blank looks.
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Having been on both the prehospital and EM side of these they are very tricky. In situations like this the adrenalin gets going and physical exam findings are obscured. Maybe the EMT missed the pulse in her excitement. Maybe you were mistaken as previously mentioned. Maybe the patient had an intermittent PEA and you were both right.

I think some additional scene assessment might help. You note that this was an "event" and that the manager was asking for a doctor from "the crowd." Was this a dinner event? Was the patient down next to a table with a big steak on it? Or was it a concert type of thing where there wasn't food available? Those factors might swing the clinical presumption one way or another.

Another point is that even if it was an airway FB the CPR would probably have been about as effective as abdominal thrusts in an unconscious patient. Remember that chest thrusts are used in the obese and pregnant.

What did the responding EMS crew find in the airway when they intubated the patient?

Finally your concern or whether or not you should have "taken over" the scene is probably misplaced. Whenever a physician tries to take over a scene it is a very contentious situation and it almost never goes well for anyone. The fact that you are a med student, i.e. you don't even have a license to present, means you almost certainly would not have been allowed to intervene. You would more likely have been removed and possible arrested had you gotten too aggressive about taking over.
 
I think some additional scene assessment might help. You note that this was an "event" and that the manager was asking for a doctor from "the crowd." Was this a dinner event? Was the patient down next to a table with a big steak on it? Or was it a concert type of thing where there wasn't food available? Those factors might swing the clinical presumption one way or another.
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first of all, the "first responder" was a person at the party (the singer in the band). i knew her and she had been drinking before this went down. she happened to be an EMT basic.

also, this was a dinner party in a large venue. i have no idea what happened or how long this guy was down because i was in a different room. when i got there (same time as her) i asked about the possibility of choking and was ignored. she did not ask about choking. everyone had been eating, drinking, and laughing for an hour. it just seemed like the first thing to look at because it can be ruled out quickly or treated.

when the real first responders arrived they immediately shocked him , then started bagging. then they screwed around trying to intubate for about two minutes until an impressive amount of vomit poured out of his mouth. after the tube was placed he was whisked away and later died in the ER. i remember wondering if all that vomit was from his gag reflex, or perhaps they were ventilating his stomach?

what you guys are saying is making me feel better about this. from what it sounds like, there is really nothing anyone could have done. but the more i ponder this, the more i think that she should have listened to me about the pulse, and spent 5 more seconds looking for one (if i can find a radial you know there has to be a good carotid). 5 seconds without CPR won't kill you.

what if he was having some sort of respiratory failure with a pulse? in that case, other than PE, rescue breaths might have saved him right?

from the start there was conflicting information about pulses and nobody looked at the airway.
 
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I was a know it all medical student. Internship/residency changed that. Your time is gonna come.
 
What if what if what if! When you build a time machine let me know. Until then just let it go. You might be telling yourself you want to be better prepared for the next time you are at a dinner party and somebody codes in front of you who may or may not have "chocked", but come on, how likely is that? Not very.
Just enjoy your life and make sure you cut your steak into tiny pieces so you too don't become a chocking victim.
 
ok, alright, it's over. lessons learned: 1) i can't spell, and poor spelling is funny 2) med students should be seen and not heard. 3) the next time i disagree with something i should refer to lesson number two.
 
Oh come now. You started this thread by being critical, so you should expect the same of others.

While there is something to be said for your lessons, here are the 2 things I think you really need to learn:
1) If you're unwilling to take action during a critical care scenario then you don't have much of a leg to stand on when criticizing those who do act.
2) The updated 2010 ACLS guidelines.

I state #1 because if you really were so darn sure that the cause of the arrest was an acute airway obstruction, then you should've tried to clear the airway before EMS arrived.

I state #2 because you don't seem to understand the "we don't do it like that anymore" response you got.
 
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WilcoWorld said:
Oh come now. You started this thread by being critical, so you should expect the same of others.

While there is something to be said for your lessons, here are the 2 things I think you really need to learn:
1) If you're unwilling to take action during a critical care scenario then you don't have much of a leg to stand on when criticizing those who did act.
2) The updated 2010 ACLS guidelines.

I state #1 because if you really were so darn sure that the cause of the arrest was an acute airway obstruction, then you should've tried to clear the airway before EMS arrived.
I state #2 because you don't seem to understand the "we don't do it like that anymore" response you got.
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that is certainly a valid point, and i think that's partly why this bothered me so much.
 
Try not to let the retrospectroscope get you down too much. You're still a med student, and as a med student I certainly would not have had the confidence to take charge of a code situation. Reflect & learn then move on...of course this is more easily said than done.
 
reedman said:
... but the more i ponder this, the more i think that she should have listened to me about the pulse, and spent 5 more seconds looking for one (if i can find a radial you know there has to be a good carotid). 5 seconds without CPR won't kill you.
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Yes, actually, 5 seconds of CPR do matter. That's one of the main "thrusts" (pun intended) of the new guidelines, that we should be working to get that CPR-free portion of the code down to a minimum.

There was a great study that had subjects check for a pulse on patients. The patients, while all quite alive, were divided into those on cardiopulmonary bypass, and those who were not. Guess what - people are both a) bad at finding a pulse that is there, and b) good at imagining a pulse that isn't!

So the lesson is, if it walks like a duck and quacks like a duck - start compressions!
 
^ that sounds like an interesting study, can you link to it?

One thing I seem to be hearing from people is: it's better to err on the side of compressions. besides a broken rib or pneumothorax, are there other risks from chest compressions?
 
J-Rad said:
This latter statement is incorrect. A witnessed, sudden collapse of a child of any age is a cardiac arrest, until proven otherwise (I have seen kids come in neurologically devastated because EMS providers and others earlier in the pipeline to the hospital, stupidly failed to remember this). If a child has a sudden witnessed collapse, priority is getting electricity available ASAP while utilizing the remaining PALS protocol. If a child is found unresponsive (unwitnessed), then yes, the likeliest course of events was pulmonary-->cardiac arrest (if they are found pulseless, unless there is a history to suggest otherwise. This is the reverse from the adult presumptions where it is most likely to be a cardiac arrest causing an unwitnessed or witnessed collapse).
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The point was that kids are more likely to choke than adults. The point was not to ignore ACLS and PALS protocol in kids because they're more likely to choke. All arrests, become "cardiac" at some point, if you don't breathe for long enough.
 
reedman said:
^ that sounds like an interesting study, can you link to it?

One thing I seem to be hearing from people is: it's better to err on the side of compressions. besides a broken rib or pneumothorax, are there other risks from chest compressions?
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many many broken ribs and possible sternum if done right=p hemothorax, never seen a ptx from CPR though. Return of Spontaneous Circulation without Neurologic resuscitation is probably the biggest risk overall. However, delaying CPR for any reason increases that risk more than starting it early.

You should look up the new AHA 2010 guidelines, there's a huge reference and explanation of them in one of the issues of Circulation and it is useful for anyone learning the new ACLS guidelines since there are a lot of conceptual changes and it provides the necessary research to back up those changes. You'll probably find the study you're looking for there.

BTW that disaster intubation scenario probably would've best been served by a combitube or Kingman device rather than the time required to intubate. You're correct that bagging increases the risk of aspiration with the force generally used to get air in. No, I don't think that an object in the airway would be the primary cause of this if that's your follow-up question. It's just a natural side effect of bagging.

as a last point, if there was food lodged in the airway, it would've been seen on direct laryngoscopy.
 
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Rendar5 said:
many many broken ribs and possible sternum if done right=p hemothorax, never seen a ptx from CPR though.
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You haven't done enough correct compressions if you haven't seen a ptx caused from CPR. 😀
 
wow guys, this thread took off way more than i thought it would!

i have looked into some ACLS algorithms and they are interesting. probably too much for me to dig into now, since i have to study for school and the step 1🙄
 
I too agree that you need to take ACLS or relearn the updated standards. Even if his airway was blocked only two attempts are made to clear it until starting chest compressions. ABD thrusts are no longer indicated or taught. Also I am confused why you are checking for a pulse in the radial? All the recent ALCS literature is indicating that compressions are much more important than breaths, and good CPR actually does cause air exchange. And to the something that looked like V-Fib leads me to believe even more than you were mistaken in feeling a pulse.

Finally you are a medical student with no medical license, you cannot take over a scene from anyone. And I agree with the above poster you could be arrested and or asked to leave.
 
i just renewed acls and while they didn't delve deeply into the new guidelines, feeling for a pulse was de-emphasized in the prehospital setting because #1, it delays cpr and #2, if the patient's unconscious, it's probably not a perfusing rhythm even if it's sinus.
 
Birdstrike said:
The point was that kids are more likely to choke than adults. The point was not to ignore ACLS and PALS protocol in kids because they're more likely to choke. All arrests, become "cardiac" at some point, if you don't breathe for long enough.
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I think maybe you misread what I wrote or I wasn't being clear. On a grand epidemiologic scale, yes, kids are more likely to choke than adults (actually, young children are). And on that scale, a primary respiratory arrest leading to cardiac arrest is more likely in all children, as I previously stated. However, again, a sudden-witnessed arrest in all ages is most likley to be cardiac. As almost all neurologically normal babies, children, and adults have some airway protective mechanisms, a child is no more likely to have no preceding signs (gagging, sputtering, etc.) and then collapse and not have a pulse from choking than the gentleman in the OP. Nor do they have instantaneous respiratory(-->cardiac arrest) from, say status asthmaticus without some harbinger of respiratory collapse. Sudden, witnessed collapse in a now pulseless pediatric patient is cardiac. Period. This is not controversial. This is why it was the exception to the "phone fast" (vs. "phone first") guideline in pediatric BLS protocols-in this scenario the rule is to "phone first", so as to expedite the arrival of an AED or other defibrillator.
 
This thread is fairly interesting and filling up with some great info. But there is a very important issue that needs a brief mention.

We have no problem if you come up to us and offer your services, especially if you are an EM Doc or PA or RN. But under no circumstances should you approach the crew and start barking orders or beating your chest, telling everyone who is in earshot that you are a doc/PA/RN and are now in charge. It doesn't work that way and we can refuse your "help". If you ask us what you can do to help however, we normally will not turn it down. Also, in most states you will have to accompany us to the ED if you gave any orders.

I only bring this up because we do run into these situations and I have had to have a physician escorted from the scene due to his interference. But i've also had good moments, like the EM Doc on-scene at an MVA with ejection. He was an attending at a major Level I in Pittsburgh and was so helpful. Never assumed, but asked what he could do to help.

So thank you to all the fantastic docs out there that provide guidance, education, and a helping hand to your friendly, neighborhood EMS companies.
 
dxu said:
This thread is fairly interesting and filling up with some great info. But there is a very important issue that needs a brief mention.

We have no problem if you come up to us and offer your services, especially if you are an EM Doc or PA or RN. But under no circumstances should you approach the crew and start barking orders or beating your chest, telling everyone who is in earshot that you are a doc/PA/RN and are now in charge. It doesn't work that way and we can refuse your "help". If you ask us what you can do to help however, we normally will not turn it down. Also, in most states you will have to accompany us to the ED if you gave any orders.

I only bring this up because we do run into these situations and I have had to have a physician escorted from the scene due to his interference. But i've also had good moments, like the EM Doc on-scene at an MVA with ejection. He was an attending at a major Level I in Pittsburgh and was so helpful. Never assumed, but asked what he could do to help.

So thank you to all the fantastic docs out there that provide guidance, education, and a helping hand to your friendly, neighborhood EMS companies.
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Someone can correct me if I'm wrong, but if a doc is willing to accept the liability and accompany the patient they actually can show up and assume control of the patient whether you want their help or not. They have an unrestricted license, we don't, nor do PA/Nurses.
 
atkinsje said:
Someone can correct me if I'm wrong, but if a doc is willing to accept the liability and accompany the patient they actually can show up and assume control of the patient whether you want their help or not. They have an unrestricted license, we don't, nor do PA/Nurses.
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It's more that if a physician wants to be allowed to provide medical orders in place of medical control (me when I'm on shift), he has to take responsibility and proceed with EMS to the hospital. If he does not, I as a med control physician will instruct EMS to defer to med control and my own instructions. EMS can of course refuse to follow their or my orders because they would be liable if they followed orders that led to a malpractice situation.
 
atkinsje said:
Someone can correct me if I'm wrong, but if a doc is willing to accept the liability and accompany the patient they actually can show up and assume control of the patient whether you want their help or not. They have an unrestricted license, we don't, nor do PA/Nurses.
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That is not entirely correct, at least in the state of Pennsylvania. According to Protocol 904, any physician on-scene must provide proof they are in fact a physician and must be informed of the liability of assuming patient care. The crew must then contact medical command and discuss the situation with their MC physician and then the on-scence physician must speak with MC and be given authorization to take control of patient care.

All of this takes a lot of time and can delay patient care. If we think it's in the patients best interest to s**t and get, we will do so regardless. But the point is we can say "no thank you". Most of us won't because we respect the training and expertise of a doc. We will probably listen to your thoughts or suggestions, but we are able to use our judgement on the situation.

That being said, there are really only a few reasons an EMS crew would not welcome or accept the assistance of an on-scene physician.

1. They are not EM, CCM, Surgery, or Gas. If you're stepping in, please be in specialty where you handle this stuff on a more regular basis. Psychs and FP normally don't run codes and handle major traumas.

2. If you're yelling and screaming about how you're a physician and everyone should listen to you, we won't. If you're in our way and slowing down patient care, we will move you out of the way. We carry 300lb + people down three flights of stairs on a regular basis. We can move you out of the way quickly.

3. If the EMS crew is experienced and has a good working relationship with the MC physicians at their home ED, the MC physicians will side with us almost 100% of the time. If we tell them we really are not happy with the on-scene physician or whatever RATIONAL reason we have, that on-scene physician becomes just another bystander.


Please don't think I am being disrespectful to any physician. You're training and knowledge is lightyears ahead of ours, no argument. But paramedics worth their salt can handle the field just fine with their partner, maybe an extra crew for extrication or CPR. I would like to think many in physicians that were involved in EMS as medics or EMTs would tend to agree with this assessment.

DU

p.s. I am not mentioning RNs who are on-scene because unless you are a flight nurse, CCU RN, or PHRN with experience then you'll probably not be much help. I just don't have a need for a medsurg nurse, sorry.
 
If the guy had choked, chest compressions were the correct move to make for an unconscious airway obstruction. You could have looked in his mouth for anything that had dislodged but that's about it. You could have tried to do mouth to mouth, but sorry, I personally wouldn't go near a stranger without some sort of barrier protection or pocket mask. Oh and if this was a primary respiratory problem, they wouldn't have just 'collapsed' without warning. Respiratory emergencies usually progress along a paradigm from distress to failure to respiratory arrest and that doesn't happen instantaneously. Even if his respiratory problem was a complete airway obstruction, he'd have up to 60 seconds before he dropped unconscious and he would have made a big scene while struggling to breathe.

If the guy didn't choke and it was a primary cardiorespiratory arrest from MI, dysrhythmia, PE, whatever, then chest compressions were still the correct first move. You can do a quick pulse check at the CAROTID (not radial), but really someone who is lying there looking dead, not breahting or breathing agonally, is probably dead.

Don't stress yourself out, you didn't do anything wrong. 👍
 
dxu said:
3. If the EMS crew is experienced and has a good working relationship with the MC physicians at their home ED, the MC physicians will side with us almost 100% of the time. If we tell them we really are not happy with the on-scene physician or whatever RATIONAL reason we have, that on-scene physician becomes just another bystander.
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👍
 
dxu said:
3. If the EMS crew is experienced and has a good working relationship with the MC physicians at their home ED, the MC physicians will side with us almost 100% of the time. If we tell them we really are not happy with the on-scene physician or whatever RATIONAL reason we have, that on-scene physician becomes just another bystander.
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This surprises me. Where I am from the MC physician has no say. If a doc is on scene, can prove they are a doc, and accept liability, it is no longer my patient. I am essentially directly under their supervision, and there simply to give them a ride and equipment. Guess I thought this was due more to the fact that physicians had an unrestricted license, it didn't occur to me that you could write a protocol and essentially void that right. Interesting.

Thanks for the varying perspectives!
 
atkinsje said:
This surprises me. Where I am from the MC physician has no say. If a doc is on scene, can prove they are a doc, and accept liability, it is no longer my patient. I am essentially directly under their supervision, and there simply to give them a ride and equipment. Guess I thought this was due more to the fact that physicians had an unrestricted license, it didn't occur to me that you could write a protocol and essentially void that right. Interesting.

Thanks for the varying perspectives!
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EMS providers operate under their MC physicians license. That is why if I am off-duty and roll up on a wreck, I can't jump on with another EMS service and help them out. Their service has different MC and have a potentially different set of protocols.
 
dxu said:
EMS providers operate under their MC physicians license. That is why if I am off-duty and roll up on a wreck, I can't jump on with another EMS service and help them out. Their service has different MC and have a potentially different set of protocols.
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This system is regional. We have a board who determines protocols and we all use the same. My medical director doesn't even work at the hospital we transport to. Thus, my MC doc is who ever is on at the local ED.
 
atkinsje said:
This system is regional. We have a board who determines protocols and we all use the same. My medical director doesn't even work at the hospital we transport to. Thus, my MC doc is who ever is on at the local ED.
Click to expand...

This is how some services work, even in PA. Like you said, regional. I am conflicted on which method I prefer. The one company I worked for, MC was the receiving hospital. The other service, I had to call MC at a particular hospital and then called the receiving hospital afterwards. It can be a mess.

My favorite setup is calling my MC for refusals, DOAs, transport decisions, or if I am heading to their hospital with a patient. If I am heading to a different facility than my MC is at, I will call and tell the doc what we've got and see what they may want done. It works pretty well this way. In any case, you should always have your home MC to call for any questions.
 
atkinsje said:
Guess I thought this was due more to the fact that physicians had an unrestricted license, it didn't occur to me that you could write a protocol and essentially void that right.
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Think of it this way. Despite having an unrestricted license, a physician can't just walk into any hospital and start doing procedures using their space and equipment, right? There is a credentialing process. Similarly, there are rules about who can make use of EMS apparatus and personnel.

In VA, if an on scene physician has already made contact with the patient when EMS arrives, and is willing to go with you to the hospital, he or she can run the call. Note that this is not the same as someone coming up in the middle of your call and wanting to take over.
 
atkinsje said:
This system is regional. We have a board who determines protocols and we all use the same. My medical director doesn't even work at the hospital we transport to. Thus, my MC doc is who ever is on at the local ED.
Click to expand...


Where are you from? Here in FL the EMS medical director has to give control to the DR on scene. We are under no obligation to listen or follow any order a DR gives us.
 
MedicFL said:
Where are you from? Here in FL the EMS medical director has to give control to the DR on scene. We are under no obligation to listen or follow any order a DR gives us.
Click to expand...

Ohio. Personally I don't like this system much. I came from a system where my medical director was EXTREMELY active. He did all our A&R's, signed off on our skills yearly, and rode several shifts with the new medics before allowing them to ride with a EMT-B partner. Plus he was the guy we dealt with for medical command, which was great because he knew us personally, made getting orders a breeze. This was when I worked full time in IN before moving for school.

In this new system I've seen my medical director once. When I first joined the dept, he signed my registry skills sheet so I could recert with them. This was more than a year ago, haven't seen him since. When I do need to speak with medical control its who ever happens to be close to nurse when I call. At times its ok, but there are times when I speak to a resident/attending I've never heard of, or met, and they of course don't know me.
 
Interesting perspectives from around the country. Here in central CT we are obliged to allow a credentialed physician to make decisions regarding a patient's care, but only if that physician will ride on the ambulance to the hospital and accept full responsibility from then on out. Buried deep in our bags we actually have a little laminated card, a note from our medical control physician that explains these rules to any prospecting doctors. I've never actually had to use it, though....

That said, good advice and an experienced helping hand is always welcome.
 
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