Guest guest Posted March 27, 2004 Report Share Posted March 27, 2004 Salvador, understand that this post does not mean to be a reflection on you personally. I see 2 problems that really bother me. 1) the possibility that any service, no matter if they are private, municipal, etc., would deny treatment, until such time as they had the patient to a point where they could not or would not be able to refuse treatment 2) the fact that a service states that you will be " turned in to TDH for decert procedures by the MD for practicing medicine without a license " for explaining and giving the patient the ability to decide on their own medical care. I am quite sure that Wes and/or Gene will chime in if I am wrong, but I have to say with regards to the latter " That's the biggest line of s*** I have heard for a long time " . Mike Re: TRENDS Hint: Load and Go. Initiate treatment in the bus while enroute. Most of the time we tell them they can sign out AMA at the ER on arrival. Re: TRENDS In a message dated 3/27/2004 2:33:05 PM Central Standard Time, mpate1104@... writes: I'm a little curious as to how you " mandate " that these patients be transported. If you have an alert, well-oriented adult patient who has been informed of the risks (and who may very well understand his illness just as well, or better, than you do), and that patient chooses to not go to the ER, how do you " mandate " that he go? Maxine Pate ----- Original Message ----- From: Salvador Capuchino Jr What if your D50 pt's BS drops again after you leave? What if your Epi pt goes into PSVT or worse? Our company mandates that everyone who receives a medication be transported to ER for f/u care/tx. If you have an alert, oriented pt who wants to refuse and hasn't been given any meds, then let them. A lot of Medical Directors mandate as Salvador says that your pt understand that if they're given meds, they're taking a ride. Because it's their license, they don't want to leave that decision making to you. For them Meds=Transport. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 27, 2004 Report Share Posted March 27, 2004 Salvador, understand that this post does not mean to be a reflection on you personally. I see 2 problems that really bother me. 1) the possibility that any service, no matter if they are private, municipal, etc., would deny treatment, until such time as they had the patient to a point where they could not or would not be able to refuse treatment 2) the fact that a service states that you will be " turned in to TDH for decert procedures by the MD for practicing medicine without a license " for explaining and giving the patient the ability to decide on their own medical care. I am quite sure that Wes and/or Gene will chime in if I am wrong, but I have to say with regards to the latter " That's the biggest line of s*** I have heard for a long time " . Mike Re: TRENDS Hint: Load and Go. Initiate treatment in the bus while enroute. Most of the time we tell them they can sign out AMA at the ER on arrival. Re: TRENDS In a message dated 3/27/2004 2:33:05 PM Central Standard Time, mpate1104@... writes: I'm a little curious as to how you " mandate " that these patients be transported. If you have an alert, well-oriented adult patient who has been informed of the risks (and who may very well understand his illness just as well, or better, than you do), and that patient chooses to not go to the ER, how do you " mandate " that he go? Maxine Pate ----- Original Message ----- From: Salvador Capuchino Jr What if your D50 pt's BS drops again after you leave? What if your Epi pt goes into PSVT or worse? Our company mandates that everyone who receives a medication be transported to ER for f/u care/tx. If you have an alert, oriented pt who wants to refuse and hasn't been given any meds, then let them. A lot of Medical Directors mandate as Salvador says that your pt understand that if they're given meds, they're taking a ride. Because it's their license, they don't want to leave that decision making to you. For them Meds=Transport. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 27, 2004 Report Share Posted March 27, 2004 Mike, I agree wholeheartedly, but I have bills to pay. They have told us that by any medic TELLING A PT THAT THEY DO NOT HAVE TO GO, is practicing medicine without a license. Whether it is or is not, I do not know for a fact. And if the MD agrees with it, then I have no choice but to either find another service or do as I am told. And there may be a few times when we may say it, but they are few and are kept to a minimum. Re: TRENDS In a message dated 3/27/2004 2:33:05 PM Central Standard Time, mpate1104@... writes: I'm a little curious as to how you " mandate " that these patients be transported. If you have an alert, well-oriented adult patient who has been informed of the risks (and who may very well understand his illness just as well, or better, than you do), and that patient chooses to not go to the ER, how do you " mandate " that he go? Maxine Pate ----- Original Message ----- From: Salvador Capuchino Jr What if your D50 pt's BS drops again after you leave? What if your Epi pt goes into PSVT or worse? Our company mandates that everyone who receives a medication be transported to ER for f/u care/tx. If you have an alert, oriented pt who wants to refuse and hasn't been given any meds, then let them. A lot of Medical Directors mandate as Salvador says that your pt understand that if they're given meds, they're taking a ride. Because it's their license, they don't want to leave that decision making to you. For them Meds=Transport. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 27, 2004 Report Share Posted March 27, 2004 , I have to add a couple of things that concern me also... 1. I am not paid to " transport patients " . I am paid to take care of patients and provide them with a standard of care. This sounds like fine management at work again. 2. Scaring patients is one of the worst things I have seen on this list in a long time. (Now that is saying a lot) You make a really great point. Neil Re: TRENDS In a message dated 3/27/2004 2:33:05 PM Central Standard Time, mpate1104@... writes: I'm a little curious as to how you " mandate " that these patients be transported. If you have an alert, well-oriented adult patient who has been informed of the risks (and who may very well understand his illness just as well, or better, than you do), and that patient chooses to not go to the ER, how do you " mandate " that he go? Maxine Pate ----- Original Message ----- From: Salvador Capuchino Jr What if your D50 pt's BS drops again after you leave? What if your Epi pt goes into PSVT or worse? Our company mandates that everyone who receives a medication be transported to ER for f/u care/tx. If you have an alert, oriented pt who wants to refuse and hasn't been given any meds, then let them. A lot of Medical Directors mandate as Salvador says that your pt understand that if they're given meds, they're taking a ride. Because it's their license, they don't want to leave that decision making to you. For them Meds=Transport. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 27, 2004 Report Share Posted March 27, 2004 You know, they way all of you all are talking, it makes me want to go work where you all do. Guys you have to understand, as you say Neil, the wonderful management at work again. But I guess most everyone has learned to put up. We used to complain at company meeting when we had them, but they fall on deaf ears. Remember, private companies are in it for the money. No income, no pay. Re: TRENDS In a message dated 3/27/2004 2:33:05 PM Central Standard Time, mpate1104@... writes: I'm a little curious as to how you " mandate " that these patients be transported. If you have an alert, well-oriented adult patient who has been informed of the risks (and who may very well understand his illness just as well, or better, than you do), and that patient chooses to not go to the ER, how do you " mandate " that he go? Maxine Pate ----- Original Message ----- From: Salvador Capuchino Jr What if your D50 pt's BS drops again after you leave? What if your Epi pt goes into PSVT or worse? Our company mandates that everyone who receives a medication be transported to ER for f/u care/tx. If you have an alert, oriented pt who wants to refuse and hasn't been given any meds, then let them. A lot of Medical Directors mandate as Salvador says that your pt understand that if they're given meds, they're taking a ride. Because it's their license, they don't want to leave that decision making to you. For them Meds=Transport. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 27, 2004 Report Share Posted March 27, 2004 Must be heaven in your region or companies. No management to tell you how to do your job as far as refusals/no transports go. And I guess I will end this topic here before I get retaliated against by anyone from the company who may be following along. Salvador Capuchino Jr EMT-Paramedic Valley EMS www.valleyems.com Re: TRENDS In a message dated 3/27/2004 2:33:05 PM Central Standard Time, mpate1104@... writes: I'm a little curious as to how you " mandate " that these patients be transported. If you have an alert, well-oriented adult patient who has been informed of the risks (and who may very well understand his illness just as well, or better, than you do), and that patient chooses to not go to the ER, how do you " mandate " that he go? Maxine Pate ----- Original Message ----- From: Salvador Capuchino Jr What if your D50 pt's BS drops again after you leave? What if your Epi pt goes into PSVT or worse? Our company mandates that everyone who receives a medication be transported to ER for f/u care/tx. If you have an alert, oriented pt who wants to refuse and hasn't been given any meds, then let them. A lot of Medical Directors mandate as Salvador says that your pt understand that if they're given meds, they're taking a ride. Because it's their license, they don't want to leave that decision making to you. For them Meds=Transport. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 27, 2004 Report Share Posted March 27, 2004 Must be heaven in your region or companies. No management to tell you how to do your job as far as refusals/no transports go. And I guess I will end this topic here before I get retaliated against by anyone from the company who may be following along. Salvador Capuchino Jr EMT-Paramedic Valley EMS www.valleyems.com Re: TRENDS In a message dated 3/27/2004 2:33:05 PM Central Standard Time, mpate1104@... writes: I'm a little curious as to how you " mandate " that these patients be transported. If you have an alert, well-oriented adult patient who has been informed of the risks (and who may very well understand his illness just as well, or better, than you do), and that patient chooses to not go to the ER, how do you " mandate " that he go? Maxine Pate ----- Original Message ----- From: Salvador Capuchino Jr What if your D50 pt's BS drops again after you leave? What if your Epi pt goes into PSVT or worse? Our company mandates that everyone who receives a medication be transported to ER for f/u care/tx. If you have an alert, oriented pt who wants to refuse and hasn't been given any meds, then let them. A lot of Medical Directors mandate as Salvador says that your pt understand that if they're given meds, they're taking a ride. Because it's their license, they don't want to leave that decision making to you. For them Meds=Transport. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 27, 2004 Report Share Posted March 27, 2004 I agree, and I believe Salvador does too, and this brings us back to one of the main points of this thread in the first place. Different types of services *do* provide different levels of care. The service that Salvador works for put more emphasis on the bottom line, as many private services will, than on the actual needs of the patient. The services I work for (knock on wood) place more emphasis on the needs of the patient, whatever they may be, than the actual bottom dollar. Is that out of fear of litigation? Perhaps at the top administration level, but I do know that my Directors on down would rather you care for the patient and explain a fiscal loss on the call, than provide care other than that which the patient needs for the sake of a financial gain. FD's aside, the level of care that you receive CAN BE based upon the type of service that you work for, regardless of the abilities of the attending medic. Now, before I become something akin to Joan of Arc, and get burned at the stake, let me add this disclaimer..... This is not true with *every* private service, nor with *every* FD. Whew... Mike Re: TRENDS , I have to add a couple of things that concern me also... 1. I am not paid to " transport patients " . I am paid to take care of patients and provide them with a standard of care. This sounds like fine management at work again. 2. Scaring patients is one of the worst things I have seen on this list in a long time. (Now that is saying a lot) You make a really great point. Neil Re: TRENDS In a message dated 3/27/2004 2:33:05 PM Central Standard Time, mpate1104@... writes: I'm a little curious as to how you " mandate " that these patients be transported. If you have an alert, well-oriented adult patient who has been informed of the risks (and who may very well understand his illness just as well, or better, than you do), and that patient chooses to not go to the ER, how do you " mandate " that he go? Maxine Pate ----- Original Message ----- From: Salvador Capuchino Jr What if your D50 pt's BS drops again after you leave? What if your Epi pt goes into PSVT or worse? Our company mandates that everyone who receives a medication be transported to ER for f/u care/tx. If you have an alert, oriented pt who wants to refuse and hasn't been given any meds, then let them. A lot of Medical Directors mandate as Salvador says that your pt understand that if they're given meds, they're taking a ride. Because it's their license, they don't want to leave that decision making to you. For them Meds=Transport. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 27, 2004 Report Share Posted March 27, 2004 I have had similar circumstances happen while working for Rural/Metro Medical Services, private as well. Rufusals were taboo. The reason was disguised as legitimate medical reason but most knew the real reason, THE BOTTOM LINE!!! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 27, 2004 Report Share Posted March 27, 2004 I have had similar circumstances happen while working for Rural/Metro Medical Services, private as well. Rufusals were taboo. The reason was disguised as legitimate medical reason but most knew the real reason, THE BOTTOM LINE!!! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 28, 2004 Report Share Posted March 28, 2004 Maxine, There are a couple of us here with licenses to practice law on the list. I might as well jump in now, even though I'm exhausted. Anyways, my question on mandatory transports is -- what happens if I don't want to let you transport me? That violates tort law on consent as well as possibly false imprisonment. Might even subject you to criminal charges. As for practicing under the medical director's license, I could see MAYBE being disallowed to practice under that doctor's license. But really, what service operating in this gray area wants to file a complaint with TDH and be subject to a full and complete investigation of the matter? My supposition is that TDH will be looking a lot more closely at the service than the individual medic if this story is correct. -Wes Ogilvie Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 28, 2004 Report Share Posted March 28, 2004 Steve I agree and I would like to hear more about your presentation. Email me off list if you can. Salvador Capuchino Jr EMT-Paramedic scapuchino@... Valley EMS www.valleyems.com Trends Salvador, I do not claim to work for the perfect company or in the perfect region. I just wanted to point out the fact that while most of us have ran across ideas and policies with which we disagree, this one really takes the cake. Everyone has their problems, but this one really needs to be addressed. As far as management goes, one thing really sticks out in my mind every time I hear someone speaking on the topic. While going through my mail I found a quote that was posted by Louis Molino. That quote stuck in my mind and has been a big topic of discussion in my " region " since it was posted. Louis, I hope you don't mind, but I am going to repost that quote because I believe it is one of the best things I have seen on this list in a long time. " We were dying for leadership, chafing under management " Everyone have a great weekend, Neil Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 28, 2004 Report Share Posted March 28, 2004 Wes and more to Maxine, I will say this again, WE PUSH FOR TRANSPORTS. WE DO NOT FORCE PEOPLE TO GO. I have posted a message with such a situation. THERE IS A DIFFERENCE BETWEEN PUSHING AND FORCING. YOU COULD SAY WE ARE STUBBORN ABOUT IT, BUT IN THE END IF YOU SAY NO, THEN OH WELL. NOW IF YOU ARE REALLY SICK AND SHOULD GO AND CONTINUE TO REFUSE WE ASK FOR A SUP AND MAYBE EVEN PD. THESE USUALLY WORK. AGAIN USUALLY. I AM AWARE OF THE LAW. I do respect your advice Wes. Please contact me privately. Salvador Capuchino Jr EMT-Paramedic scapuchino@... Valley EMS www.valleyems.com Re: TRENDS Maxine, There are a couple of us here with licenses to practice law on the list. I might as well jump in now, even though I'm exhausted. Anyways, my question on mandatory transports is -- what happens if I don't want to let you transport me? That violates tort law on consent as well as possibly false imprisonment. Might even subject you to criminal charges. As for practicing under the medical director's license, I could see MAYBE being disallowed to practice under that doctor's license. But really, what service operating in this gray area wants to file a complaint with TDH and be subject to a full and complete investigation of the matter? My supposition is that TDH will be looking a lot more closely at the service than the individual medic if this story is correct. -Wes Ogilvie Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 28, 2004 Report Share Posted March 28, 2004 I have inserted comments below. GG In a message dated 3/28/2004 8:01:28 AM Central Standard Time, SDralle@... writes: I wanted to coment on this discussion as it is related to a topic I am hoping to present at the conference. There are three big problems with patient refusals. Depending on how they are taken it represents poor patient care, significant liability for the medic and company and damages the financial health of the agency. Now, before you set your e-mail to flame I want you to consider some basic issues with this problem. First, I will state clearly that I would not suppor the termination of an employee for accepting signed refusals from a patient. I would only support termination after there is significant evidence of that employee engaging in repeated 'medic initiated' refusals. That is, the medic " talks the patient out of transport " . There have been several studies (I am on the road so I do have them with me to cite them, but can later if needed) that indicate we are very bad at predicting the need for ED care or hospitalization. I think this is releated primarily to the lack of diagnostic equipment in the field and training focused on the identification and management of emergencies rather than on the ruling out of specific conditions. (But that is just my theory) You are correct that there is poor correlation. However, it may result from a number of things, not the least of which is inadequate care at the hospital. We have experienced more than once taking a patient to a certain hospital only to fine them almost beat us home, and two days later take them again, this time in critical condition from a condition that was ignored or missed in the hospital. Aside from that, a friend who is a former Paramedic, now in 1st year residency, tells me that he now looks at cases in a very different way from the way that he did as a Paramedic. Why? He has more diagnostic knowledge and tools; he has more experience with disease progressions and outcomes, and also has the luxury of not having to make a transport decision. Patients that are " iffy " are simply parked in observation for a while till the labs come back and then a decision is made. We can't sit with patients for a few hours waiting to see how they do. I would argue that most of us want to transport our patient and do not intentionally talk patients out of transport but I would also argue that our language (both spoken and implied) communicates something very different. When you respond to the home of an 80 year old patient complaining of headache times four hours and slight HTN what do you ask when it comes to transport, " Do you want to go to the hospital? " I think an arugement could clearly be made that this question actually communicates to the patient, " You do not need to go but I will take you. " The problem is, we would not do that with a patient that had a knife sticking out of his chest, would we? We would say, if anything, " What hospital do you want to go to? " More likely we would just start preperations for transport. Correct again. Our verbal communication and body language tells the patient a lot. Perhaps we should learn better communications skills. But there are pitfalls in saying too much about what we think the patient's problems are. We run the risk of getting too far into diagnosis and practice of medicine, which makes our medical directors very queasy indeed. I prefer to say that we cannot rule out a serious condition in the field and that our best advice is to seek care in the hospital. I sometimes explore alternative transportation with family, friends, or going to a clinic, but I resist refusing to take the patient. In my mind that's an invitation to disaster and a lawsuit. Now, what do you do about the patient with a broken finger but no transportation? Depends. If it's a kid and his mom with no car or no money for gas, then I cheerfully transport. If it's a system abuser, I'm not so eager. I see alternative means of transport as being something that would work for some systems; I know it has been tried, but I have the sense that it has never worked well. Anybody have any knowledge or ideas about this? GG This is just a partial sample of the arguement I make in my presentation but I did not think any of you would like to read a 5,000 word essay on the topic in this format. I would just challenge you to think about what your body language is and how your language changes with the age and complaint of the patient. As for the patient with a hang nail, warn of their risks and let them refuse. Steve Dralle, EMT-P San Of course, these are just my opinions and I do not speak for my agency. Trends Salvador, I do not claim to work for the perfect company or in the perfect region. I just wanted to point out the fact that while most of us have ran across ideas and policies with which we disagree, this one really takes the cake. Everyone has their problems, but this one really needs to be addressed. As far as management goes, one thing really sticks out in my mind every time I hear someone speaking on the topic. While going through my mail I found a quote that was posted by Louis Molino. That quote stuck in my mind and has been a big topic of discussion in my " region " since it was posted. Louis, I hope you don't mind, but I am going to repost that quote because I believe it is one of the best things I have seen on this list in a long time. " We were dying for leadership, chafing under management " Everyone have a great weekend, Neil Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 28, 2004 Report Share Posted March 28, 2004 In a message dated 3/28/2004 11:58:53 PM Central Standard Time, hatfield@... writes: Secondly, and I hate to play semantics, but my medical director *does not* have the authority to 'yank my patch' he never has and never will. He *does* have the authority to refuse to allow me to practice under his license which would pretty much leave me unemployed. I've seen med dir yank patches, they have pull & lots of cooperation from TDH. If nothing else, blackballing is VERY real in the EMS community. Just be careful. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 28, 2004 Report Share Posted March 28, 2004 In a message dated 3/29/2004 12:37:09 AM Central Standard Time, Etlaesium@... writes: That's a whole 'nother thread, and in tune with Lance's post, to become an extension of the physician, we would be called upon to make more intense clinical decisions. WE would have to, dare I say it? Diagnose things and not be afraid. In essence, we would be doing the exact opposite of what you are talking about. This thread has gone round and round, and I posed the question, and never received a good answer. Does every patient who dials 911 require ambulance transport to the hospital? No. Paramedic initiated refusals are OK, they really are, they are new, and they may be scary to those who don't have the confidence in their skills, but they really are acceptable. What have we always had drilled into our heads? YOU DON'T DIAGNOSE IN THE FIELD. Treat what you see and get them to the ER for further eval. Again, even in the best of assessments, we still don't possess the support services (CT, X-ray, labs) that ER's do in order to make full, concise diagnoses. Case in point: a few years back I got called for a minor MVA. Pt was 70+ male COAx4, with a scratch on his hand. Thought maybe he'd looked down and just didn't see the semi stopped in front of him. He was on his way to the pharmacy to pick up his meds. Could even tell me that the paper bag with the pill bottles were under his driver's seat. Pt had rear-ended a semi at about 30 mph. COMPLETELY STABLE, minor damage to his vehicle, flirted with me all the way to the ER. Pt was former military, so I took him to BAMC (military trauma center & also his primary hospital) called in Code II pt report. Sweet old man, doc treated him like a waste of time. Went back to the ER a couple of hours later & the ER doc was hot after my ass, why? Because the pt had an aortic tear and he thought I should've come in Code III. Know what I told him? How was I supposed to know this? It took sophisticated diagnostic imagery for you to find it, sorry, the CT/X-ray on my truck is broken today... Doc hated me till he PCS'ed out, but would you have done something differently? What if you'd refused this pt because he could've driven himself in and he coded in the WR? I am confident in my skills, but not conceited about them. My pt lived because I gave him a ride. That's a DAMN GOOD feeling... Food for thought.... Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 28, 2004 Report Share Posted March 28, 2004 Gene, I was right behind you for awhile, but I have to make a few of my own observations. First and foremost, I should say up front that I am a firm believer in Paramedic initiated refusals. If you or your service employs a Paramedic that would cause you fear by being unable to decipher what patients need ambulance transport, and which ones don't, then either you have hired him/her because they have 'a patch and a pulse', they need some remedial training, or they need to be terminated. I do agree that there are those among us who would blatantly talk a patient out of transport to the ER, policing ourselves without a lynch rope will often find those and again, either offer remedial training, or eradicate them from the field. From: wegandy1938@... >>I would only support >>termination after there is significant evidence of that employee engaging >>in >>repeated 'medic initiated' refusals. If in fact the patient has a medical issue or condition which needs to be evaluated by a physician *right now*, then those patients by all means need to be transported via ambulance. If the patient does not have an emergency medical condition, and we cannot confuse *emergency medical condition*, with *medical condition*, then they can have alternatives explained to them. If the same patient is calling for the same issue, and that issue still is not a medical emergency, then in my honest opinion, repeated medic initiated refusals are warranted. Alternatives may be either follow up with their personal physician at his/her office, or, POV, or other ideas. >>I think this is >>releated primarily to the lack of diagnostic equipment in the field and >>training >>focused on the identification and management of emergencies rather than on >>the ruling out of specific conditions. If a medic has strong assessment skills, than the two should happen simultaneously, one should be able to rule out certain conditions, while at the same time identify any medical emergencies. >>We have experienced more than once taking a patient to a certain hospital >>only to fine them almost beat us home, and two days later take them again, >>this >>time in critical condition from a condition that was ignored or missed in >>the >>hospital. One could arguably state then that they apparently didn't need ambulance transport the first time around, they did however require some evaluation, and they did require transport the second time. >>I would argue that most of us want to transport our patient and do not >>intentionally talk patients out of transport but I would also argue that >>our >>language (both spoken and implied) communicates something very different. >>When you respond to the home of an 80 year old patient complaining of >>headache times four hours and slight HTN what do you ask when it comes to >>transport, " Do you want to go to the hospital? " I think an arugement >>could clearly be made that this question actually communicates to the >>patient, " You do not need to go but I will take you. " The problem is, we >>would not do that with a patient that had a knife sticking out of his >>chest, would we? We would say, if anything, " What hospital do you want to >>go to? " The patient with the knife sticking out of his chest speaks for itself, the patient with the HA and HTN, needs to be evaluated. Neither of these patients fit a category of medic initiated refusals in my opinion. I think the training that we receive already incorporates some diagnostic skills, we can call it different things, but " a rose by any other name is still a sweet smelling rose " , we do make differential diagnosis in the field. Why are we so afraid to use the knowledge that we have? Tell you what though, treat us like we are idiots, and we sure get pissed off. >>We run the risk of getting too far into diagnosis and practice of >>medicine, >>which makes our medical directors very queasy indeed. I prefer to say >>that we cannot rule out a serious condition in the field and that our best >>advice is to seek care in the hospital. I don't have a problem telling a patient that they need to be seen, and they need to be seen in the ER, but where does that require EMS transport? >>This is just a partial sample of the arguement I make in my presentation >>but >>I did not think any of you would like to read a 5,000 word essay on the >>topic in this format. Not on the list server, but I would be more than happy to read it off line, if you have it, send it. >>As for the patient with a hang nail, warn of their risks and let them >>refuse. Is this not the perfect patient for a Paramedic initiated refusal? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 28, 2004 Report Share Posted March 28, 2004 , First, I can assure you that I am well aware of whose license I practice under. Secondly, and I hate to play semantics, but my medical director *does not* have the authority to 'yank my patch' he never has and never will. He *does* have the authority to refuse to allow me to practice under his license which would pretty much leave me unemployed. Pretty definitive difference between the two. Your service, your company, your director, your owner, your partner. None of them *start* the 'de certification' process, they do the same thing your Medical Director does, they file a complaint/grievance, and TDH does their thing. They investigate, and come to a conclusion. Back to my original comment. For any service to say that they will turn you in to TDH for decertification, is an incredibly ridiculous attempt at intimidation. I cannot count the times I have pissed off physicians for following my protocols, of those, about 10-20% swear that they will file a compliant with TDH, and have my patch taken away. I stand by my care, and I still have my patch 14 years later. Do I violate my own protocols? Nope. But I have the luxury of working under medical directors who have a sense of good patient care. 50% patient care, 50% politics? I tend to lean a little towards 10% patient care, 90% politics. Respectfully, Mike -----Original Message----- From: cllw602@... It may be a line of bs when it comes to our opinion, but as I said before, you're practicing under THEIR license. If they've clearly stated in their protocols that if you push meds, you take a ride, and you don't get the proper documentation (a lot of medical directors want you to call them or secondary medical control to get " permission " ) and follow their rules, they can and will yank your patch. Especially in private services. They are there to make money, no ride, no money. It's 1/2 medicine, 1/2 politics. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 28, 2004 Report Share Posted March 28, 2004 Mike, I will agree with you that not every patient requires transport to the ED, but " paramedic-initiated refusals " are not (IMNSHO) worth the trouble. I do agree with the concept, though. Every patient that is able to provide informed consent for treatment must do so and transportation to the ED is a part of the treatment plan that requires it. I am not against providing the patient with the required information to make an informed decision, but to say, " Ma'am, I'm not taking you to the hospital " would be a gross disservice. On the other hand, the expectation should not be to transport every patient to the hospital just because they called 9-1-1. The expectation should be to offer transport for those that require or request it. Most people that call for EMS did not know how to handle a certain event and can be assured that they are doing the right thing (i.e. child with a moderate fever x 1 hour and Tylenol/Motrin given by parent). We as EMS professionals should have an instrument that allows us to formulate an adequate treatment plan that includes transport to the ED as necessary without having to obtain a written and informed refusal from the patient when it is not necessary. I think that this reinforces the " call the ambulance for a ride to the hospital " mindset. Just some thoughts. Mike Re: RE: Trends That's a whole 'nother thread, and in tune with Lance's post, to become an extension of the physician, we would be called upon to make more intense clinical decisions. WE would have to, dare I say it? Diagnose things and not be afraid. In essence, we would be doing the exact opposite of what you are talking about. This thread has gone round and round, and I posed the question, and never received a good answer. Does every patient who dials 911 require ambulance transport to the hospital? No. Paramedic initiated refusals are OK, they really are, they are new, and they may be scary to those who don't have the confidence in their skills, but they really are acceptable. I don't deny that the call to 911 may be because they were afraid, or hurt, etc., being afraid, with no medical issues, does not constitute a medical necessity for an ambulance. Stubbed toes? 3 day old fevers? These need ambulance transport to the ER? I think not. Mike Re: Trends > > > > Steve says good things, but the big city medics such as those San > > > > dewds described by one writer will eventually compose their own > > obituary. As > > those who pay the bills begin to realize that they're paying a bunch of > > high-powered LazyBoys to take shortcuts and avoid using their skills, > > they'll figure > > out a way to get rid of them. Unions or no unions. > > > > GG > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 28, 2004 Report Share Posted March 28, 2004 Mike, I will agree with you that not every patient requires transport to the ED, but " paramedic-initiated refusals " are not (IMNSHO) worth the trouble. I do agree with the concept, though. Every patient that is able to provide informed consent for treatment must do so and transportation to the ED is a part of the treatment plan that requires it. I am not against providing the patient with the required information to make an informed decision, but to say, " Ma'am, I'm not taking you to the hospital " would be a gross disservice. On the other hand, the expectation should not be to transport every patient to the hospital just because they called 9-1-1. The expectation should be to offer transport for those that require or request it. Most people that call for EMS did not know how to handle a certain event and can be assured that they are doing the right thing (i.e. child with a moderate fever x 1 hour and Tylenol/Motrin given by parent). We as EMS professionals should have an instrument that allows us to formulate an adequate treatment plan that includes transport to the ED as necessary without having to obtain a written and informed refusal from the patient when it is not necessary. I think that this reinforces the " call the ambulance for a ride to the hospital " mindset. Just some thoughts. Mike Re: RE: Trends That's a whole 'nother thread, and in tune with Lance's post, to become an extension of the physician, we would be called upon to make more intense clinical decisions. WE would have to, dare I say it? Diagnose things and not be afraid. In essence, we would be doing the exact opposite of what you are talking about. This thread has gone round and round, and I posed the question, and never received a good answer. Does every patient who dials 911 require ambulance transport to the hospital? No. Paramedic initiated refusals are OK, they really are, they are new, and they may be scary to those who don't have the confidence in their skills, but they really are acceptable. I don't deny that the call to 911 may be because they were afraid, or hurt, etc., being afraid, with no medical issues, does not constitute a medical necessity for an ambulance. Stubbed toes? 3 day old fevers? These need ambulance transport to the ER? I think not. Mike Re: Trends > > > > Steve says good things, but the big city medics such as those San > > > > dewds described by one writer will eventually compose their own > > obituary. As > > those who pay the bills begin to realize that they're paying a bunch of > > high-powered LazyBoys to take shortcuts and avoid using their skills, > > they'll figure > > out a way to get rid of them. Unions or no unions. > > > > GG > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 28, 2004 Report Share Posted March 28, 2004 My ideal service would have a PA or Assistant Medical Director roving. If I have pt that I determine does not need to go by bus then call him in to assess and prescribe if needed. Re: RE: Trends In a message dated 3/29/2004 12:37:09 AM Central Standard Time, Etlaesium@... writes: That's a whole 'nother thread, and in tune with Lance's post, to become an extension of the physician, we would be called upon to make more intense clinical decisions. WE would have to, dare I say it? Diagnose things and not be afraid. In essence, we would be doing the exact opposite of what you are talking about. This thread has gone round and round, and I posed the question, and never received a good answer. Does every patient who dials 911 require ambulance transport to the hospital? No. Paramedic initiated refusals are OK, they really are, they are new, and they may be scary to those who don't have the confidence in their skills, but they really are acceptable. What have we always had drilled into our heads? YOU DON'T DIAGNOSE IN THE FIELD. Treat what you see and get them to the ER for further eval. Again, even in the best of assessments, we still don't possess the support services (CT, X-ray, labs) that ER's do in order to make full, concise diagnoses. Case in point: a few years back I got called for a minor MVA. Pt was 70+ male COAx4, with a scratch on his hand. Thought maybe he'd looked down and just didn't see the semi stopped in front of him. He was on his way to the pharmacy to pick up his meds. Could even tell me that the paper bag with the pill bottles were under his driver's seat. Pt had rear-ended a semi at about 30 mph. COMPLETELY STABLE, minor damage to his vehicle, flirted with me all the way to the ER. Pt was former military, so I took him to BAMC (military trauma center & also his primary hospital) called in Code II pt report. Sweet old man, doc treated him like a waste of time. Went back to the ER a couple of hours later & the ER doc was hot after my ass, why? Because the pt had an aortic tear and he thought I should've come in Code III. Know what I told him? How was I supposed to know this? It took sophisticated diagnostic imagery for you to find it, sorry, the CT/X-ray on my truck is broken today... Doc hated me till he PCS'ed out, but would you have done something differently? What if you'd refused this pt because he could've driven himself in and he coded in the WR? I am confident in my skills, but not conceited about them. My pt lived because I gave him a ride. That's a DAMN GOOD feeling... Food for thought.... Quote Link to comment Share on other sites More sharing options...
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