Trends

[Guest guest]

I appreciate Steve's comments but must make one clarification. I did not

mean to suggest that the changes I prophesied would necessarily do the most good

for the most patients. I was merely reciting what I foresee happening, good

or bad. I personally would like to see a paramedic or two on every truck

everywhere.

Also, although I believe that I did say that I understood that I was

generalizing, I do want to reiterate that I did not intend to paint all medics

in the

big city systems as being lazy and incompetent. However, it has been my

unfortunate experience to observe substandard and poor practices in the big

Texas FD EMS services. I also will say that I took my paramedic training in

Houston 23 years ago and that I felt that the standard of care then was

excellent.

The medics from Houston FD who trained me were topnotch in every way.

Apologies to any medic out there in Big D, SA, and Houston who does stand for

quality and does the right thing.

GG.

In a message dated 3/26/2004 8:46:07 AM Central Standard Time,

slemming@... writes:

I would like to make some brief comments on Gene's original statement. I

appreciate his line of thinking in that he believes this would do the most good

for the most patients. I agree the rural and frontier areas deserve much

attention. This could be started by shifting grant monies from being given to

the

larger cities. It appears many times that grants are awarded to these larger

entities so that it " appears " that they are being fair and not just playing to

the

volunteer and small community services. Should a large city with millions in

its budget be awarded tens of thousands more, or should it go to an all

volunteer department trying to scrape by with donations and bake sales and 14

employees? Seems simple to me.

I believe that his theory was started after reviewing some of the published

studies. We should be careful and not make sweeping changes to our treatment

and systems based on the data of one or a few studies. Rather, these things

should be surveyed over a period of time and the eventual decision is based on

what is right for our patients. Most importantly, the citizenry of your

community

decides the level of service that you provide. If they wish you to be staffed

to the hilt with the most current prehospital practices and highest level of

provider, that's what they will pay for. If not, they will run the majority as

BLS units with some ALS or MICU units.

Be careful in painting the fire based EMS systems with all one brush stroke.

I did my paramedic internship in Dallas and can attest partially with what he

says. In my station and shift, some could not care less about being on " the

box " and went through the motions every shift, but one guy in particular joined

the department just so he could be a medic. Needless to say, he was very

knowledgeable and professional and took me under his wing to make sure I was

learning the proper way.

One of the larger issues is developing the smaller and volunteer EMS systems

so that higher levels of certification and licensure are there, adequately

trained and compensated. Training is one of the first areas to get hit

budget-wise and gets side tracked when more important issues arise. Some of the

smaller

agencies don't have full-time training officers. This oversight is even worse

in volunteer departments for the most part.

I wholeheartedly agree the EMS Basic skill level should be advanced, but then

we as a " profession " should advance as well. Maybe the newly formed TDH or an

independent consultant group could mail a questionnaire to every provider in

the state to assess staffing levels, certification/licensure, budget, level of

care, and critical need. This could also be done anonymously through a

website link so that no one would be in fear of speaking " officially " and

receiving

the wrath of the employer who would try to sugar coat the response.

Just my individual thoughts. It's a good road to start on to see where it

leads. Who knows maybe we could effect long term change.

Lt. Steve Lemming, AAS, LP

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Trends

While driving the West Texas highways as I frequently do, I have lots of time

to think. Yes, I know that driving and thinking can be dangerous, but I do

it anyway.

Yesterday I read the abstract of the new study that shows that trauma

patients who were ventilated with BVM did better than those who were

endotracheally

intubated. So much for intubation of the trauma victim.

As more and more evidence based studies come online it becomes more and more

apparent that good EMS can be carried on much of the time without Paramedics.

Basic EMTs now can use the Combitube, and ought to be using the Combitube,

can give Epi 1:1000, NTG, aerosol bronchodilators, and defibrillate with the

AED.

This leads me to reconsider the deployment of EMTs and Paramedics.

Currently, Paramedics are concentrated in large urban areas where scene to

hospital transports are likely to be relatively short. There are many fewer

Paramedics per capita in the rural and frontier areas.

The big city Paramedics, at least in the case of Houston, San , and

Dallas, are fire service based. These fire services have been notoriously

poor

at motivating Paramedics toward improved educational standards and improved

standard of care. The existing culture in FD EMS, particularly the larger

ones,

is that medics are 2nd class citizens to firefighters, and are either doing

penance in Hell for sins committed or going through the prescribed years of

Purgatory on their way to a better life as a full time firefighter.

[i would be afraid of being tarred and feathered, drawn and quartered,

beaten, shot, burned, and hanged by some of those medics for making those

statements

except for the fact that there are no medics from any of the large fire

departments who take part in this list. So they'll never know. ]

Big city FD medics do not seek to improve their knowledge base as a rule, do

not seek to improve or expand their clinical skills, and don't want a wider

scope of practice. And why should they? They're so close to good hospitals

that unless they follow the California model of sitting on the scene while

starting IVs and giving their patients manicures and pedicures prior to

transport,

they seldom get to do the advanced skills that they now know how to do.

Therefore, it makes sense to seriously restrict the number of Paramedics in

those services. EMTs with an AED, a Combitube, a Geezer Squeezer and a

mindset for immediate transport can do just about all that's necessary for

those

patients who are going to survive.

If the AED works, flying squad Paramedics arrive to give the

antidysrhythmics if the scene is more than 8 minutes from the nearest

hospital, or after

defibrillating, the EMTs scoop and haul and get them into an ER within that

time.

For those where the AED doesn't work, load and go, do the Combitube and

Geezer Squeezer enroute and get them to the hospital where they can properly

be

pronounced dead.

Paramedics in the flyers would not be firefighters at all, would be a

different category of worker assigned as 3rd service liaison to the fire

service,

would have advanced training, and because there would be relatively few of

them,

they would get to do their advanced stuff often enough to stay in practice.

Their training would be similar to the Australian model which is about 5

times

more comprehensive than most Paramedic education/training in this country.

Paramedics would be sent to calls where medical skills are needed, where

pharmacology will make a difference and IV access is needed, and where

complicated

dysrhythmias are going on and the patient is beyond the selected txp time to

hospital. Paramedics would be deployed around the perimeters rather in the

center of the city so that they could run both in and out. Their deployment

would be mostly limited to call locations where transports to hospital would

be

more than a few minutes.

Fire services would send nobody to Paramedic school, but they might add IV

access by saline lock to the basic skills, thereby often having access

immediately available either to responding Paramedics or to hospital ER pe

rsonnel.

Much training money would be saved and EMTs could be rotated on and off the

ambulances much more easily since their skills sets would be less. EMTs have

always had great extrication, lifting and moving, and other basic skills.

There would be no need for them to worry about going much further than that.

Thus, the Paramedic concentration would shift from city where it is not

needed, to country, where it is.

Rural services have a much greater need for Paramedics with advanced

assessment, diagnostic, and clinical skills than are usually needed in large

cities,

simply because they are often looking at transport times of anywhere from

half

an hour at best to 2 or 3 hours. Much more pharmacology is used by those

medics, and although they do not get as many calls as big city medics, the

calls

they do get tend to more likely be seriously sick people. Therefore

Paramedics

are needed more in the rural areas.

The rural paramedics I know are by and large a lot better educated and better

practitioners than the large city FD Paramedics I have witnessed in action.

They HAVE to be better because they've got their patients for a Loooooong

time

and they are apt to be Reeeeally sick. Most of the rural medics I know study

relentlessly, spend lots of time between calls looking up cool EMS stuff on

the Internet and talking over calls. They are more interested in their

patients because they are not as fatigued every shift and not as burnt out.

They

also may know their patients as neighbors, which is a powerful incentive for

excellence.

Yes, exceptions always exist, and generalities are dangerous, but generally

speaking I think many will agree with me.

So, in sum, I predict that in the next 10 years we'll see a redistribution

of Paramedics from city center to rural areas, and most big city services

will

revert to mostly Basic EMT staffing. Rural areas will finally find a way to

fund better services when governments get on top of the learning curve and

figure it out. Rural EMS costs a pittance of what big cities spend.

Your thoughts?

Mr. Grady

[Guest guest]

Most do, that's your medical director's license that he/she spent 11+ years

getting.... You should NEVER " no load " anyone you've administered meds to, if

their BS is dropped so low that they can't correct it themselves, there's a

good chance that there's an underlying reason that needs follow up care. We may

perform a lot of the same functions that ER doctors do, but we don't have the

education or the resources (lab, CT, X-ray) that they do. That's why they get

the big bucks and we don't.

If you want to be able to make decisions like a doctor, then spend the time,

money and effort, and go to med school like they did.

[Guest guest]

In a message dated 3/27/2004 11:52:38 AM Central Standard Time,

hatfield@... writes:

We need to be able to explain to our patients that there is not a need

to be seen in the ER right now, this could just as easily be followed up

at your Dr.'s office in the morning. If our assessment skills are

strong, if our decision making skills are good, than we can help

alleviate some strain on overburdened EMS systems, as well as the

overburdened ER's.

IF you're talking about stubbed toes, that's fine. But if you're wrong, there

can be serious consequences. I can agree that both EMS systems and ERs alike

are overburdened by people using EMS as a taxi service or the " if I go in by

ambulance I'll get taken back right away and seen quicker " mentality and using

the ER as their PCP, but that's when the ER and EMS personnel need to get

together and set forth guidelines and standards for " no loading. " Once a pt has

been seen & evaluated by a doctor in the ER, he reserves the right to tell them

that they're not going to die in the next 24 hours, so they need to f/u with

their PCP. But there again, he has the education & malpractice insurance to be

able to do that. Besides if they turned them away at the triage desk telling

them that their complaint was BS, then it's an EMTALA violation. You figure

EMTALA came around because too much of that was happening. Do we really want

some

type of EMTALA laws regulating EMS? It would be much easier to be practical.

If it's a foot pain that started 4 months ago at 2 am thing, feel free to

offer up your opinion that they'd be better served by their PCP, if you're

having

to give Xopenex for SOB, err on the side of caution and take them in. It's

better than being called back 2 hours later when they're in respiratory arrest.

[Guest guest]

What if it's not a case of failure to eat or take insulin?

Hypoglycemia, also called low blood sugar, occurs when your blood glucose

(blood sugar) level drops too low to provide enough energy for your body's

activities. Hypoglycemia is uncommon except as a side effect of diabetes

treatment,

but it can result from other medications or diseases, hormone or enzyme

deficiencies, or tumors.

Can you diagnose that in the field? Are you really willing to take the

chance???

[Guest guest]

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.

[Guest guest]

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 recieves a

medication be transported to ER for f/u care/tx.

TRENDS

Question:

Does everyone transport every patient you medicate to the ER? 25 g

of D50-patient is now A & Ox4, just got a little out of whack. Breathing

treatment with 0.3 mg of epi. Patient A & Ox4, lungs clear, O2 98%. Do all of

these

patients need to go to the ER? Some patients call because their car is broke,

ran out of meds, or some other problem. They all should get the same

assessment and care but do they need transport to back log an already

understaffed ER?

If we could use the doc-in-the-box clinics and return the ER to what it is

supposed to be the world would be rosy. Thoughts?

Barry Meffert

[Guest guest]

Guess I have the same question. Especially when in comes to your

hypoglycemic patients, you push the D50 and they come around. Most don't

want to go to the hospital after that. It is a condition they have had for

years and understand completely. How can you force a patient to get in the

box if they don't want to. And furthermore why would you want to. As long

as they are A & Ox4 and understand the risks involved, it is their choice

regardless of the interventions you have already started.

Quinten

FF/NREMTP

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.

[Guest guest]

I understand that your company mandates it, but what does your medical

director say, (personal opinion) it may be the same, not trying to pick

things apart, I am merely curious to know if your Med. Dir. Also

believes that every patient who receives any medication from EMS needs

to be transported.

If it is solely the belief of your company, than one could reason that

it is a financial only decision, or at least based mostly on financial

reasons.

While there are some instances that require a patient to be transported,

there are an equal number who don't need it. You cannot categorize all

into either side of the debate.

I can't count the number of patients anymore who I gave D50 to, wait for

a bit, reassess, and then bug out. Same with Albuterol/Atrovent/Xopenex

breathing treatments.

To me, this is what we need to become to some degree. We need to be an

extension of our physicians; we need to be the liaison between the

patient and the ER, not just the method of transportation.

We need to be able to explain to our patients that there is not a need

to be seen in the ER right now, this could just as easily be followed up

at your Dr.'s office in the morning. If our assessment skills are

strong, if our decision making skills are good, than we can help

alleviate some strain on overburdened EMS systems, as well as the

overburdened ER's.

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

recieves a medication be transported to ER for f/u care/tx.

From: ultrahog2001@...

Does everyone transport every patient you medicate to the ER? 25 g

of D50-patient is now A & Ox4, just got a little out of whack.

Breathing

treatment with 0.3 mg of epi. Patient A & Ox4, lungs clear, O2 98%.

[Guest guest]

Not here to criticize anyone's company or policies but that seems to be a

bad way to treat patients. If I take a blood sugar and it is to low for the

machine to pick-up I push the D50 then and there. Not wait for the time it

takes to get them on a stretcher and on the unit. (Takes a while to move a

300pound patient in some cases) If the patient comes around and says they

don't want to go and they are fully aware of the risks, I notify my ER Doc

on duty, get signatures and move on to the next call. I don't think I have

ever told anyone that they can just go AMA if they get tired of being in the

ER.

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.

[Guest guest]

What further care will be provided in an ED for a patient that failed to take

his/her insulin or failed to eat at the appropriate time or any of the other

routine cases that we see daily in the diabetic patient. It is not playing MD

it is Paramedicine Technology.

We should be a true extension of the physician and emergency department not

merely a mode of transportation.

There are times when the ED needs to be taken to the patient and there are times

when the patients needs to be taken to the ED.

Just my thoughts,

, LP

Re: TRENDS

Most do, that's your medical director's license that he/she spent 11+ years

getting.... You should NEVER " no load " anyone you've administered meds to, if

their BS is dropped so low that they can't correct it themselves, there's a

good chance that there's an underlying reason that needs follow up care. We

may

perform a lot of the same functions that ER doctors do, but we don't have the

education or the resources (lab, CT, X-ray) that they do. That's why they get

the big bucks and we don't.

If you want to be able to make decisions like a doctor, then spend the time,

money and effort, and go to med school like they did.

[Guest guest]

Actually, the literature has shown that it relatively safe to administer

D50W to a hypoglycemic and allow the patient to refuse transport. The same

holds true with heroin addicts in Australia. Usually, paramedics will

administer naloxone, wake them up and allow them to refuse transport.

Several studies have looked at long-term follow-up of these two sub-groups

and found them safe for treat and release.

BEB

Re: TRENDS

Most do, that's your medical director's license that he/she spent 11+ years

getting.... You should NEVER " no load " anyone you've administered meds to,

if

their BS is dropped so low that they can't correct it themselves, there's a

good chance that there's an underlying reason that needs follow up care. We

may

perform a lot of the same functions that ER doctors do, but we don't have

the

education or the resources (lab, CT, X-ray) that they do. That's why they

get

the big bucks and we don't.

If you want to be able to make decisions like a doctor, then spend the time,

money and effort, and go to med school like they did.

[Guest guest]

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 recieves a

medication be transported to ER for f/u care/tx.

[Guest guest]

If it's not, then you would have found that in your assessment. Or if it

is in association with other issues, you would have found that as well,

either through the patient or family members. If the patient remains

with an altered LOC, there is no way to obtain a reputable history,

therefore they go.

Point is, you cannot group all patients together, there are some

Diabetics that you can 'fix' and leave at home, same with asthma

patients, and a myriad of other ailments.

That's the key here, a THOROUGH assessment, not a finger prick, an amp

of D50, another finger prick, then out the door. No different than one

breathing treatment, no matter what flavor, then out the door.

A thorough assessment followed by an appropriate treatment, followed by

another assessment. Then you make a decision, with the patient as to the

necessity of transportation vs. follow up with their own physician.

Am I willing to diagnose a tumor in the field, of course not, am I

willing to administer D50 or a breathing treatment in the field, then

let the patient make an informed decision as to taking an ambulance to

the ER after I do an assessment? Sure, I do it now.

When in doubt, I transport.

I have to rely on my knowledge, what I learned in school, what I learned

on the streets, and what countless old timers have taught me.

Mike

Re: TRENDS

What if it's not a case of failure to eat or take insulin?

Hypoglycemia, also called low blood sugar, occurs when your blood

glucose

(blood sugar) level drops too low to provide enough energy for your

body's

activities. Hypoglycemia is uncommon except as a side effect of diabetes

treatment,

but it can result from other medications or diseases, hormone or enzyme

deficiencies, or tumors.

Can you diagnose that in the field? Are you really willing to take the

chance???

[Guest guest]

How very true. What's going to happen if you " stay & play " and pushing D50

doesn't work? Or you push too much and they go from 40 to 240?

[Guest guest]

In a message dated 3/27/2004 4:31:41 PM Central Standard Time,

hatfield@... writes:

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. "

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.

[Guest guest]

Was not trying to give a 'cookbook' problem and answer. Just wanted to

point that telling a patient to go AMA when they get in the ER is not good

patient care. And we should not transport just for the sake of transporting

so we can make money of the call. When a patient makes a rational decision

not to go to the hospital we should listen and not think about how much

money our CEO is losing out on.

OK I am off my soapbox for the night.

Quinten

FF/EMT-P

Re: TRENDS

How very true. What's going to happen if you " stay & play " and pushing D50

doesn't work? Or you push too much and they go from 40 to 240?

[Guest guest]

Was not trying to give a 'cookbook' problem and answer. Just wanted to

point that telling a patient to go AMA when they get in the ER is not good

patient care. And we should not transport just for the sake of transporting

so we can make money of the call. When a patient makes a rational decision

not to go to the hospital we should listen and not think about how much

money our CEO is losing out on.

OK I am off my soapbox for the night.

Quinten

FF/EMT-P

Re: TRENDS

How very true. What's going to happen if you " stay & play " and pushing D50

doesn't work? Or you push too much and they go from 40 to 240?

[Guest guest]

I do strongly agree with you on that. However, our CEO has said that refusals

need to stop. That we are practicing medicine by telling a pt that he/she does

not need to go. The COO has said that anyone who is heard saying this will be

turned in to TDH for decert procedures by the MD for practicing medicine without

a license. Also comments have been made and reading between the

lines...transport is recommended in every case due to financial reasons. We are

getting paid to do a job (transport pts). If we are not bringing in income,

then why should we get paid. I tend to agree to some part, but yes I see that a

stubbed toe at midnight with the bed is no reason to go to the ER.

RE: TRENDS

I understand that your company mandates it, but what does your medical

director say, (personal opinion) it may be the same, not trying to pick

things apart, I am merely curious to know if your Med. Dir. Also

believes that every patient who receives any medication from EMS needs

to be transported.

If it is solely the belief of your company, than one could reason that

it is a financial only decision, or at least based mostly on financial

reasons.

While there are some instances that require a patient to be transported,

there are an equal number who don't need it. You cannot categorize all

into either side of the debate.

I can't count the number of patients anymore who I gave D50 to, wait for

a bit, reassess, and then bug out. Same with Albuterol/Atrovent/Xopenex

breathing treatments.

To me, this is what we need to become to some degree. We need to be an

extension of our physicians; we need to be the liaison between the

patient and the ER, not just the method of transportation.

We need to be able to explain to our patients that there is not a need

to be seen in the ER right now, this could just as easily be followed up

at your Dr.'s office in the morning. If our assessment skills are

strong, if our decision making skills are good, than we can help

alleviate some strain on overburdened EMS systems, as well as the

overburdened ER's.

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

recieves a medication be transported to ER for f/u care/tx.

From: ultrahog2001@...

Does everyone transport every patient you medicate to the ER? 25 g

of D50-patient is now A & Ox4, just got a little out of whack.

Breathing

treatment with 0.3 mg of epi. Patient A & Ox4, lungs clear, O2 98%.

------------------------------------------------------------------------------

[Guest guest]

,

I think what Maxine is talking about, (I am sure she will correct me if

I'm wrong)is that if the patient is alert and oriented, he/she clearly

has the option and the legal right to tell you " I don't want to go. " How

then can you mandate that you take them?

Maxine, do I have that right?

On a side note with regards to making your patient understand that if

they are given meds, they have to go, how do you explain to a patient

with a blood sugar of 40, giving you the 1000 yard stare, and oblivious

to the world around them, " Maam, we are going to give you medications,

and if we give them to you, we MUST take you to the hospital " , if they

have a blood sugar of 40, they are in no condition to make a decision,

therefore we treat under implied consent, with a blood sugar of 120,

alert and oriented, and under informed consent, they tell you to p***

off and leave you alone, your mandate means nothing to them.

The next time you go, you could well load them first, and hold off on

the D50 till you get outside the ER, and run like hell to get them

inside before they wake up, or, you could say that since they didn't

cooperate with your mandate (I have used that word for lack of a better

term) you aren't going to give them anything.

I always give the speech about, " The next time I come out here for the

same thing, we all have to be in agreement that you are gonna go with

us, agreed? " They usually do.

Mike

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.

[Guest guest]

You can scare them into going. And although it may be lying, what can I really

do to keep admin off my back?

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.

[Guest guest]

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.

[Guest guest]

Also our refusal rate was pretty high after midnite. So now, if you get a

refusal or get cancelled enroute, you are still up for the next call. And you

will continue to be until you transport.

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.

[Guest guest]

If I have an alert, oriented patient who chooses to refuse, whether he has

been given meds or not, I have to let him. Even if he agreed to transport

prior to the meds, and then changes his mind after the meds, I have no

choice but to let him, as an alert and well-oriented adult cannot legally be

transported against his will.

Would a person who was not oriented prior to the meds (as in the

hypoglycemic patient) even understand what he is agreeing to when you tell

him that he has to be transported after the meds? If he doesn't understand,

is his agreement binding even after he becomes well-oriented?

I understand the need for caution. I understand that a proper assessment

and reassessment is critical. I understand the need to make sure that the

patient is making an informed decision. I understand the need for complete

and accurate documentation. But I sure don't understand how anyone can

" mandate " that a well-oriented adult patient be transported, whether he

wants to go or not. I know that if I'm that patient and you're that medic

and I say I'm not going, then you're not taking me, no matter what your

department or your Medical Director says. And that's a decision that hasn't

been made by the medic--it's a decision that has been made by me, the

patient. Patients do have that right.

Maxine Pate

>

> 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.

>

[Guest guest]

Private.

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.

[Guest guest]

Now well, of course it depends on every situation. We all know that not every

call is the same. If blood sugar is too low, then I treat on-scene. If pt is

too heavy for rapid load and go, then I treat on scene. I do believe everyone

knows the difference. Sorry to make you assume I treat otherwise.

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.