Re: Ability of Paramedics to select patients who will be admitted to hospital

January 15, 2004

Very well said Gene.

Joby Berkley

Ability of Paramedics to select patients who will be

admitted to hospital

> I'm prompted to do a rant. I haven't done one in quite a while. So I'm

> entitled. Right?

>

> I can't find the study, and perhaps Dr. Bledsoe or somebody else can help

> find it, but I recall that there is a study that attempted to measure the

ability

> of paramedics to predict which of their patients will be evaluated and

sent

> home vs. those who will be admitted to the hospital.

>

> The study showed poor ability of paramedics to identify those patients who

> will need hospitalization. Maybe somebody saved the reference to that

study.

> If so, please post it.

>

> There have also been studies that showed that triage nurses have a rather

> poor track record in ranking patients in order that they should be seen.

Studies

> have shown that triage nurses tend to down-triage patients.

>

> Why is this so? Well, for a variety of reasons.

>

> First, and probably most important, is bias. Everybody has his own

biases.

> For some it's racial; for others it's cultural, gender, ethnic, language,

> appearance, financial status, age, place of residence, and condition bias.

> Condition bias is one of the lurking pitfalls in triage. What I mean by

that is

> developing tunnel vision based upon a known or perceived pre-existing

condition

> which clouds our abilities to objectively evaluate our patients.

>

> Example: Elderly lady falls and sustained contusion and hematoma to

> forehead. Spouse says that she suffers from dementia. Paramedic unable

to determine

> whether patient's less than totally coherent responses are due to existing

> condition or resulting from the trauma to the head. Spouse says that

physician

> has been changing medications and withholding some that she has been takin

g in

> an attempt to figure out what is causing the dementia.

>

> Patient is transported to ED where CT shows a brain tumor. Her physician

> developed tunnel vision about her condition and overlooked one of the

simplest

> and most fundamental diagnostic tests we possess, the CT scan of the head.

>

> Bias leads us to jump to conclusions and limits our investigations into

> patient history of past conditions, medications, new signs and symptoms,

and

> history of the current complaint. We assume that we know what's happening

and we

> determine that the patient does not need our services. We often are under

> stress from system status management policies which encourage us to spend

less

> time on each call. We may be tired and cranky. We also may just not like

this

> patient. So we make a fatal mistake. We determine that our patient, who

we

> know, is complaining of abdominal pain, and we know that he does that

often; he

> is an alcoholic, and does not take care of himself. So we encourage him

to

> take some Pepto-Bismol and sign the release. Unfortunately he has a

dissecting

> aneurysm which is responsible for his S/S, and because we are biased we

failed

> to do a thorough and complete assessment and missed it. He dies at home.

We

> are called on the carpet. Maybe sued.

>

> Other reasons why paramedics are less than 100% in predicting who will be

> admitted:

>

> Lack of basic diagnostic test capability. We cannot do labs that would

show

> us that our patient has a WBC of 31,000. We cannot x-ray the head and see

the

> bleed.

>

> We CAN use cardiac enzyme markers, but they must NEVER be used as a basis

to

> deny transport and treatment.

>

> There are many other factors that come into play in the correct diagnosis

of

> a patient's problems. They have to do with the knowledge and experience

of

> the evaluator among other things.

>

> A first year resident has a lot more background knowledge than we usually

> have, plus she has a chief resident and an attending to consult and who is

> looking over her shoulder to make sure that she doesn't screw up too

badly. We have

> no such system.

>

> I personally have plenty of background knowledge and plenty of experience;

> yet, I do not for one moment think that I am competent to determine that a

> patient who presents with a vague medical complaint that is real to that

patient

> does not need to go to the hospital. I would not be even if I had an

x-ray

> machine, CT, and MRI on my ambulance, and a laboratory with full

capabilities,

> because I do not as a paramedic possess the knowledge, education,

training, and

> experience necessary to correctly order and interpret tests.

>

> Of course there are cases, such as the famous sore toe, that will always

be

> brought up as being egregious abuses of the system. Agreed. Except that

you

> must thoroughly understand the etiology of the sore toe before you can

make

> that determination. True, the isolated mashed finger can go by private

car.

> That's not what I'm talking about. I'm talking about the patient with

multiple

> problems, some of which are socially abhorrent to us, and lead us to make

> biased decisions.

>

> If all paramedics functioned in the 99th percentile of ability, I would be

> less reluctant to encourage decisions not to transport. But there is wide

> variance in the abilities of street paramedics going back to the fact that

we allow

> medics to be certified/licensed with the most minimal educational

> requirements. ( There are also wide variances in physicians'

performances. I just

> ditched one this week because he wouldn't listen to me.)

>

> Every service determines through policy and procedure how it will deal

with

> the difficult patient. Often the practices that it condones are not

written

> policy; rather they are cultural practices that have been traditionally

> accepted. This is where trouble begins.

>

> I am just as angry about system abusers as anyone, maybe more angry than

> some. Believe me, I see one several times a week. But I contain my anger

because

> I realize that if I ever let my anger control my assessment and treatment

of

> my patient I will inevitably run into trouble. Passion has little place

in

> acute care. If I " act out " to this patient and insult her, I will be

lowering

> myself to her level. I am a professional. I do not lose my cool because

I'm

> provoked by a patient. I recognize that while I'm dealing with her

problems,

> which seem self-inflicted and trivial to me, perhaps another patient who

needs

> my services may be dying. But that's life in the big city. That's the

way

> the system is designed. We take care of the patient that we have before

us.

>

> Are other paradigms possible? Of course. We could completely redesign

our

> systems through legislation and rules. There are many models that we

could

> adopt that are different from the ones we now use; but until those models

are

> adopted and explained to our constituents, we have no choice but to adhere

to the

> fundamentals of street care: Assess, treat, and transport. Do not judge,

> and when communicating, be sure that your use of colloquial and street

language

> is appropriate for the situation. Never denigrate a patient in any way.

Yes,

> rant, rave, and shout about them after you're done with them, curse them,

> punch your fist through the wall, kick your dog, throw out the cat, but

don't

> abuse your patient.

>

> Best,

>

> GG

>

January 15, 2004

Very well said Gene.

Joby Berkley

Ability of Paramedics to select patients who will be

admitted to hospital

> I'm prompted to do a rant. I haven't done one in quite a while. So I'm

> entitled. Right?

>

> I can't find the study, and perhaps Dr. Bledsoe or somebody else can help

> find it, but I recall that there is a study that attempted to measure the

ability

> of paramedics to predict which of their patients will be evaluated and

sent

> home vs. those who will be admitted to the hospital.

>

> The study showed poor ability of paramedics to identify those patients who

> will need hospitalization. Maybe somebody saved the reference to that

study.

> If so, please post it.

>

> There have also been studies that showed that triage nurses have a rather

> poor track record in ranking patients in order that they should be seen.

Studies

> have shown that triage nurses tend to down-triage patients.

>

> Why is this so? Well, for a variety of reasons.

>

> First, and probably most important, is bias. Everybody has his own

biases.

> For some it's racial; for others it's cultural, gender, ethnic, language,

> appearance, financial status, age, place of residence, and condition bias.

> Condition bias is one of the lurking pitfalls in triage. What I mean by

that is

> developing tunnel vision based upon a known or perceived pre-existing

condition

> which clouds our abilities to objectively evaluate our patients.

>

> Example: Elderly lady falls and sustained contusion and hematoma to

> forehead. Spouse says that she suffers from dementia. Paramedic unable

to determine

> whether patient's less than totally coherent responses are due to existing

> condition or resulting from the trauma to the head. Spouse says that

physician

> has been changing medications and withholding some that she has been takin

g in

> an attempt to figure out what is causing the dementia.

>

> Patient is transported to ED where CT shows a brain tumor. Her physician

> developed tunnel vision about her condition and overlooked one of the

simplest

> and most fundamental diagnostic tests we possess, the CT scan of the head.

>

> Bias leads us to jump to conclusions and limits our investigations into

> patient history of past conditions, medications, new signs and symptoms,

and

> history of the current complaint. We assume that we know what's happening

and we

> determine that the patient does not need our services. We often are under

> stress from system status management policies which encourage us to spend

less

> time on each call. We may be tired and cranky. We also may just not like

this

> patient. So we make a fatal mistake. We determine that our patient, who

we

> know, is complaining of abdominal pain, and we know that he does that

often; he

> is an alcoholic, and does not take care of himself. So we encourage him

to

> take some Pepto-Bismol and sign the release. Unfortunately he has a

dissecting

> aneurysm which is responsible for his S/S, and because we are biased we

failed

> to do a thorough and complete assessment and missed it. He dies at home.

We

> are called on the carpet. Maybe sued.

>

> Other reasons why paramedics are less than 100% in predicting who will be

> admitted:

>

> Lack of basic diagnostic test capability. We cannot do labs that would

show

> us that our patient has a WBC of 31,000. We cannot x-ray the head and see

the

> bleed.

>

> We CAN use cardiac enzyme markers, but they must NEVER be used as a basis

to

> deny transport and treatment.

>

> There are many other factors that come into play in the correct diagnosis

of

> a patient's problems. They have to do with the knowledge and experience

of

> the evaluator among other things.

>

> A first year resident has a lot more background knowledge than we usually

> have, plus she has a chief resident and an attending to consult and who is

> looking over her shoulder to make sure that she doesn't screw up too

badly. We have

> no such system.

>

> I personally have plenty of background knowledge and plenty of experience;

> yet, I do not for one moment think that I am competent to determine that a

> patient who presents with a vague medical complaint that is real to that

patient

> does not need to go to the hospital. I would not be even if I had an

x-ray

> machine, CT, and MRI on my ambulance, and a laboratory with full

capabilities,

> because I do not as a paramedic possess the knowledge, education,

training, and

> experience necessary to correctly order and interpret tests.

>

> Of course there are cases, such as the famous sore toe, that will always

be

> brought up as being egregious abuses of the system. Agreed. Except that

you

> must thoroughly understand the etiology of the sore toe before you can

make

> that determination. True, the isolated mashed finger can go by private

car.

> That's not what I'm talking about. I'm talking about the patient with

multiple

> problems, some of which are socially abhorrent to us, and lead us to make

> biased decisions.

>

> If all paramedics functioned in the 99th percentile of ability, I would be

> less reluctant to encourage decisions not to transport. But there is wide

> variance in the abilities of street paramedics going back to the fact that

we allow

> medics to be certified/licensed with the most minimal educational

> requirements. ( There are also wide variances in physicians'

performances. I just

> ditched one this week because he wouldn't listen to me.)

>

> Every service determines through policy and procedure how it will deal

with

> the difficult patient. Often the practices that it condones are not

written

> policy; rather they are cultural practices that have been traditionally

> accepted. This is where trouble begins.

>

> I am just as angry about system abusers as anyone, maybe more angry than

> some. Believe me, I see one several times a week. But I contain my anger

because

> I realize that if I ever let my anger control my assessment and treatment

of

> my patient I will inevitably run into trouble. Passion has little place

in

> acute care. If I " act out " to this patient and insult her, I will be

lowering

> myself to her level. I am a professional. I do not lose my cool because

I'm

> provoked by a patient. I recognize that while I'm dealing with her

problems,

> which seem self-inflicted and trivial to me, perhaps another patient who

needs

> my services may be dying. But that's life in the big city. That's the

way

> the system is designed. We take care of the patient that we have before

us.

>

> Are other paradigms possible? Of course. We could completely redesign

our

> systems through legislation and rules. There are many models that we

could

> adopt that are different from the ones we now use; but until those models

are

> adopted and explained to our constituents, we have no choice but to adhere

to the

> fundamentals of street care: Assess, treat, and transport. Do not judge,

> and when communicating, be sure that your use of colloquial and street

language

> is appropriate for the situation. Never denigrate a patient in any way.

Yes,

> rant, rave, and shout about them after you're done with them, curse them,

> punch your fist through the wall, kick your dog, throw out the cat, but

don't

> abuse your patient.

>

> Best,

>

> GG

>

January 16, 2004

Just for grins and so I can play too, I have one of these for you to see what

folks would do in this case.

Patient info: 15 y/o H female - 3 calls to school in a week for " passed out "

All three trips patient presents the same - is " passed out " but on first 2

trips responds to loud verbal STERN stimuli with " I don't feel good " . Her

eyelids were fluttering, obviously hyperventilating (tachypneic, deep, c/o

hands tingling, etc.) First trip all vital signs pretty normal - just a tad

tachycardic. Blood glucose normal. ECG normal except rate at 110. Lungs

clear. Rest of survey negative. Mother in attendance already stating

patient has hx of depression and has had recent family trauma. Mother says

she was going to take patient to doctor POV to get her checked.

Second trip exactly the same except patient has systolic pressure in 150's.

Nothing else different. Transported to ED for evaluation for anything from

psych to possible drug ingestion - antihistamine? Who knows?

Third trip very next day after release from hospital ED with no real

diagnosis. Same exact complaints except now she is

supposededly " unconscious " . No real major differences in exam. Doesn't like

ammonia inhalant (flutters lids and such). Loaded to ambulance where she

begins attempting to take off seatbelts and becomes " combative " . Is talked

down again. Still hyperventilates when you don't talk her out of it.

Thoughts?

Jane Hill

January 16, 2004