Guest guest Posted October 4, 2006 Report Share Posted October 4, 2006 It is a multifaceted problem that has been created over the past 30+ years the system has been in place. I think the answer lies in the middle of changing SOG's to not allow the medics to electively no-ride people (BTW, there is a SOG related to " Mandatory Transports " but compliance is sporadic at best) this would most likely require a significant capital investment as well as the hiring of a bunch of people to either place more MICU's in-service or make Paramedic Engines/Truck Companies to supplement due to the volume of calls. Then you have the QI part that needs to be greatly enhanced, again this will require money to hire more people to do chart audits, ride along evaluations etc etc etc, this is not likely to happen either. Regarding the education part of the problem, I don't think it is the school (UTSW) I believe it is due to new medics being partnered with old medics and over time their bad habits either rub off or are forced on them and the problem goes on and on. I know that DFR has recently got their own Medical Director (just for them), he came for San Francisco I believe and from what I hear is going to be a great asset for DFR and probably the system in general. Again, this is not a bash of DFR, there are other departments within the system that do the same things you just don't hear much about them, this is a system problem in general. Lee Re: Re: Patient Refusal Forms of Little Value The problem with 'taxi patients' is that many studies have shown that paramedics are poor at determining who needs treatment and transportation, and who will actually be admitted to the hospital. One of the reasons is that we don't have access to radiology and labs, but, sadly, another one is that we are not trained well in general medicine. So about the time you think that Miss EMS Abuser has called you one too many times, and you're mad and tempted to " no-ride " her, that's the time that she actually has PID and dies from septic shock. And low and behold, out of the woodwork come relatives who see her death as winning the lottery. I few days ago I posted a list of differential diagnoses for abdominal pain. We can find similar lists for practically every pain that can be described. I am not skilled in lie detection, although I have my ideas, but if challenged in Court, I would never be able to explain why I denied a patient treatment and transport for a " headache. " I have had lots of experience in talking with people who lie, and I have been fooled. Not often, but enough times that I never rely upon my gut reaction when making a treatment/transport decision. Even polygraphs are not reliable enough to be admissible in court. I see us using alternative means of transport for those patients who are looking for a taxi ride. That would take the pressure from overworked EMS crews. But if that is not available, then we must do the right thing FOR THE PATIENT, NOT FOR US, OR THE SERVICE. Most of the abusers have some medical problems and lots of social problems. Drug addiction is a medical problem, and lack of transportation is a social problem. The bad thing about it all is that we do not have a pervasive public health plan for dealing with these patients. The public health service people don't talk to EMS, and they should. But communication is two way. We don't reach out to the public health service people and say, " HEY, we've got some big problems caused by these prostitutes and drug abusers who use our services for other reasons than for emergency medical care. We need to get together and work out some plans. " Unfortunately, that almost never happens. I would like to hear from anybody who has a plan in place to deal with those patients through social services and public health resources. Gene G. In a message dated 10/3/06 6:41:08 PM, paramedicbbt@... <mailto:paramedicbbt%40yahoo.com> <mailto:paramedicbbt%40yahoo.com> writes: > > So surely for the person who called for the taxi service with the below > statement was turned in for false report of an emergency??? ? > > We filled in a report and all that jazz, but I highly doubt anything came of > it. This was in the hardcore ghetto; the woman (and I use the term loosely) > had no permanent address, had a history of all sorts of criminal and > drug-related charges, etc. etc. If we actually prosecuted everyone that pulled that, > there would be no cops left to run the county. (They usually have enough > presence of mind to make up some excuse like " I have a headache " when we started > questioning them after the " oh, my ride's here; I'll meet ya at Sha-naynay's > crib in a few " statement when we walked in.) I thought maybe the idea that > the service won't get paid might make a difference, but nah. > > Blake- > TX LP, NREMT-P, TX EMSI > AIM: SinaptiK > " Medicine, the only profession that labors > incessantly to destroy the reason for its > existence. " Bryce > > > Facebook me! > > ------------ -------- -------- -- > Get your email and more, right on the new Yahoo.com > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 4, 2006 Report Share Posted October 4, 2006 Who is the new EMS med director for DFW from San Francisco referenced in a recent post??? Kirk D. Mahon, MD, ABEM 6106 Keller Springs Rd Dallas, TX 75248 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 5, 2006 Report Share Posted October 5, 2006 I think it's interesting that I wrote that post before I knew about the latest debacle from the Dallas system. Just goes to show what can happen when medics " assume " that someone only has indigestion. Gene > > Gene, > > We see those patients every day in the ED, and much of the time WE CAN'T > make a diagnosis. So we get them admitted for observation and further testing, > up to and including endoscopy. > > Randy > > R. (Randy) Loflin, M.D., FACEP > Associate Professor > Medical Director, City of El Paso EMSS > > Re: Patient Refusal Forms of Little Value > > The main reason I don't refuse patients who I'm tempted to think don't have > anything serious wrong with them is NOT what I know, but what I know that I > DON'T know. > > For example, here are some of the causes of abdominal pain: > > parietal peritoneal inflammation due to infection (appendix, PID) > parietal peritoneal inflammation due to chemical irritation (perforated > gastric or peptic ulcer; pancreatitis, Mittelschmerz, ruptured ectopic > pregnancy) > inflammation of bowel wall > Crohn's disease, > ulcerative colitis, > microscopic colitis > diverticulitis > gastroenteritis > lactose intolerance > celiac sprue > sarcoidosis > vasculitis > mechanical obstruction of hollow viscera > gallstones > vascular disturbances > embolism > thrombosis > vascular rupture > torsional occlusion (volvulus) > sickle cell anemia > renal vein entrapment > superior mesenteric artery syndrome (nutcracker syndrome) > mesenteric traction > muscle trauma > muscular infection > distention of visceral surfaces such as hepatic or renal capsule > referred pain from the thorax (MI, pneumonia), spine, genitals (testicular > torsion) > metabolic disturbance (lead poisoning, black widow spider bite, uremia, DKA, > porphyria, C1-esterase inhibitor deficiency, adrenal insufficiency) > tabes dorsalis > herpes zoster > Lyme disease > Irritable Bowel Syndrome > torsion of the ovary, endometriosis > diarrhea > meningitis > cholecystitis > pyelonephritis > hepatitis > mesenteric adenitis > subdiaphragmatic abscess > cancer of the ovary, bowel, stomach, liver, kidney, etc > ascites > > And there are surely others > > Any medic who feels comfortable telling someone with vague abdominal pain > that it's just an upset stomach is playing with fire, and will soon see the > judge > and jury. And that's the kindest thing I can say about such a person. > > If I were a board certified general surgeon or gastroenterologist in the > ambulance, I still wouldn't street such a patient. Yet paramedics do it > every > day. > > It boggles the mind. > > Gene G. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 5, 2006 Report Share Posted October 5, 2006 Gene, We see those patients every day in the ED, and much of the time WE CAN'T make a diagnosis. So we get them admitted for observation and further testing, up to and including endoscopy. Randy R. (Randy) Loflin, M.D., FACEP Associate Professor Medical Director, City of El Paso EMSS Re: Patient Refusal Forms of Little Value The main reason I don't refuse patients who I'm tempted to think don't have anything serious wrong with them is NOT what I know, but what I know that I DON'T know. For example, here are some of the causes of abdominal pain: parietal peritoneal inflammation due to infection (appendix, PID) parietal peritoneal inflammation due to chemical irritation (perforated gastric or peptic ulcer; pancreatitis, Mittelschmerz, ruptured ectopic pregnancy) inflammation of bowel wall Crohn's disease, ulcerative colitis, microscopic colitis diverticulitis gastroenteritis lactose intolerance celiac sprue sarcoidosis vasculitis mechanical obstruction of hollow viscera gallstones vascular disturbances embolism thrombosis vascular rupture torsional occlusion (volvulus) sickle cell anemia renal vein entrapment superior mesenteric artery syndrome (nutcracker syndrome) mesenteric traction muscle trauma muscular infection distention of visceral surfaces such as hepatic or renal capsule referred pain from the thorax (MI, pneumonia), spine, genitals (testicular torsion) metabolic disturbance (lead poisoning, black widow spider bite, uremia, DKA, porphyria, C1-esterase inhibitor deficiency, adrenal insufficiency) tabes dorsalis herpes zoster Lyme disease Irritable Bowel Syndrome torsion of the ovary, endometriosis diarrhea meningitis cholecystitis pyelonephritis hepatitis mesenteric adenitis subdiaphragmatic abscess cancer of the ovary, bowel, stomach, liver, kidney, etc ascites And there are surely others Any medic who feels comfortable telling someone with vague abdominal pain that it's just an upset stomach is playing with fire, and will soon see the judge and jury. And that's the kindest thing I can say about such a person. If I were a board certified general surgeon or gastroenterologist in the ambulance, I still wouldn't street such a patient. Yet paramedics do it every day. It boggles the mind. Gene G. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 5, 2006 Report Share Posted October 5, 2006 Marshall Isaacs is the new Assistant Medical Director. Pepe is the Medical Director. Randy R. (Randy) Loflin, M.D., FACEP Associate Professor Medical Director, City of El Paso EMSS RE: Re: Patient Refusal Forms of Little Value Who is the new EMS med director for DFW from San Francisco referenced in a recent post??? Kirk D. Mahon, MD, ABEM 6106 Keller Springs Rd Dallas, TX 75248 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 5, 2006 Report Share Posted October 5, 2006 Gene, I have look for the article you all spoke of about the patient with abdominal pain being left at the house by DFD and later dying. Let me know where you all found this article. Maxie Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 14, 2006 Report Share Posted October 14, 2006 I know I am late on this one, but there are also some ER docs that are so burned out they welcome refusals. I know of very few doctors who would trust any paramedic enough to allow an on-line refusal. The times we have taken patients to the ER that really didn't need to go by ambulance the ER staff to include the ER doc, complain about why we transported the patient. And on top of that they hold the patient on your stretcher for hours until a bed becomes available. We have been stuck in the ER for up to 5 hours with one patient. Now that ERs are starting to triage and send non-emergency patients to an urgent care clinic when they can't pay in advance for services, we can weed out those patients. Hopefully soon we too can refer these patients to an urgent care center and hopefully even with on-line medical control. So it's not always about the " lazy medic. " Everyone here at some point in their career has pushed a refusal. But what about when you have a service that cuts down on the refusal rate by keeping that unit up for calls until a transport is made and the crews have to lie to a patient about their medical condition just to get a transport? Salvador Capuchino Jr EMT-P --- Kirk Mahon wrote: > Henry, > > I totally agree with you. And I should have said, > " I know one system that > needs fixing. " I have had experience with several > that do NOT have the > issues discussed. > > Would anybody condone the following scenario: > 90 year old lady has syncope and family calls 911. > She comes to and is > asymptomatic on EMS arrival. An ekg is done and > since it is normal she > doesn;'t come to the ER. What do you think just > happened there? > > The official llights and sirens and badges would > assure anybody that they > are dealing with a proper authority to make that > decision. However, syncope > (especially in an older person) is a problem that > needs a lot of detailed > history, exam, labs, and monitoring. They need a > physician evaluation. An > ecg is not enough and it is a disservice to use it > at the scene if your are > then going to let people assume that the " machine > that goes beep " says > everything is ok and use that information to not > transport....this is > similar to the case mentioned in the article. > > If you are worried enough to do an ecg then you had > damn well better > transport. I am a huge believer in autonomy (not > paternalism) but you need > to make sure that the patient gets in the box. The > real truth is, if they > don't, there is a very good chance it is due to your > communication about > your assessment and the ecg that weighed in. That > is dangerous. > > Kirk D. Mahon, MD, ABEM > > 6106 Keller Springs Rd > Dallas, TX 75248 > > > > > > Quote Link to comment Share on other sites More sharing options...
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