Responsibility

Came into work this morning and was talking to the boss here about the call I did earlier in the week involving the suicide. He has a police background so I was interested in his perspective.

He was sympathetic to my decision making. The guy was dead, and had I worked him, I would have jammed up a lot of people, with no change in the result. We talked about how on one hand the state has protocols for EMS that suggest patients need to be worked regardless of fatal injury and on the other hand the average police department has no idea such protocols exist so they go on taping up obvious death scenes as crime scenes, and medics are slowed down on the way to presume bodies that may not quite meet the state standard. They wait outside the yellow tape while the photos are taken, then are given access to call the time. There was obviously no cross communication in the development of the EMS protocols.

Another example is the state regulation that requires a police officer to ride in the back of the ambulance if the patient is handcuffed. The police departments all have policies that allow the officer to follow in their cruiser. Now the reason for the regulation is in case the person becomes suddenly ill, maybe stops breathing and needs to be unhandcuffed, what do you do if you don't have the handcuff keys readily available (i.e. in your immediate hands rather than in the car following)? Answer -- you are screwed. The patient is screwed.

Now sometimes the cop will ride in the back, but most of the time, they follow. You can be a hard head and insist that they ride in the back, but then that jams them up, they need to get another officer to the scene when they may already be holding police calls. Sometimes they'll just tell you no -- this is how its going to go down. I try not to argue with people wearing guns -- unless I think it is really important. They are just not aware of the regulation. I doubt they were consulted when the regulation was written.

What do you do? You may only be a few blocks from the hospital. Why be a stickler when the only reason you are going to the hospital is because the patient needs a few stitches? They are fully healthy and alert. Why be an obstructionist?

They will tell you one thing in a class, but then there is the reality of the street.

I try to use common sense on a case by case basis. Sometimes I ask the officer to ride in back if I think there might be a problem with the patient being cuffed. If I don't think there will be a problem, I go with the flow.

You need regulations, but you also need common sense.

I will note that I raised this issue at a regional MAC meeting many years ago -- just pointing out that it was a problem medics faced -- being asked to violate the regs in the due course of the daily job. A letter suppossedly went out to police departments for a third time, but nothing changed.

Some would say the only way to do this job is to be black and white on everything. Others would say flexibility and common sense must rule. I am in the latter camp. Of course there is responsibility to be accepted whenever the issue is gray.

But I will accept that responsibility.

That's what being a paramedic is about.

In my opinion.

***

An interesting sidelight of our conversation was the officer mentioned he had recently been on a call where he and other officers got there. The person was in arrest. They put on a defibrillator -- no shock advised -- they started CPR. A paramedic arrived. Put the patient on the monitor. The patient was asystole. She told them to stop CPR. She said she was calling the patient dead. The officer left, leaving another officer on scene. He later heard from the other officer that a second paramedic showed up, and after CPR had been interrupted for ten minutes, for some reason the second medic convinced the first medic that they needed to work the patient. So they ended up transporting the patient to the hospital, doing CPR -- all after a ten minute interruption.

Now I wasn't there so maybe I have some of the facts wrong. It sounds like the first medic failed to follow the protocols that require you to do 20 minutes of ALS rescusitation on medical asystole patients before calling the patient dead. Did she not know the protocols? Was she lazy? Or were there other factors that I don't know about that led her to say stop? Maybe there was some rigor in the jaw? I have been on calls where the cops were doing CPR, but the patient had early riggor so I stopped. Like I have written before dead is dead. So what happened when the second medic showed up? Why did they start working the patient again, and not just working for 20 minutes on scene and then presuming dead, but working and transporting? I guess you would have had to have been there.

What does it all mean? There are many decisions to be made. Everyone has their lines of demarcation. Some are inside mine. Some are outside.

I have argued against having medics have to call the physician to get permission to presume. I want to be able to decide for myself, but when I hear of people not working people who I would have worked, then I think maybe it is neccessary.

Bottom line is the State Medical Committee is working on rewriting the state guidelines and not only do they need to be rewritten, but each medic needs to know what is in them and how much leeway they have in interpreting them. Good guidelines would allow common sense to prevail. But what if people don't have common sense? That is a whole other problem, and a very scary one.

***

Only call today a cancer patient with chest pain.