tag:blogger.com,1999:blog-5498194182629204271.post9078706225147777931..comments2023-09-26T12:58:21.651+00:00Comments on The Paramedic's Diary: Wet Footed StuFruXfhttp://www.blogger.com/profile/08189044083128101123noreply@blogger.comBlogger6125tag:blogger.com,1999:blog-5498194182629204271.post-524120176917549982010-02-03T09:13:01.043+00:002010-02-03T09:13:01.043+00:00SLM
I am indeed in the public domain and, whether...SLM<br /><br />I am indeed in the public domain and, whether negative or not, I always appreciate candid opinions if they are not just personal attacks.I also appreciate that you are a fellow clinician who is offering a viewpoint but I am old enough and ugly enough to take responsibility for myself and this is what drives me to respond in a somewhat defensive manner, for which I apologise because it can often be misinterpreted as reactive.<br /><br />My remit on the car is to convey whenever possible; that's how it works here. Not every sector shares this belief and I have had discussions with other FRU medics who tell me that what I do is 'unsafe' or 'risky'. I am NOT careless and blase about my job, career or patients and am well aware of the consequences of my actions should I get something wrong. This is what gives me clinical autonomy and the capacity to make decisions.<br /><br />Now, if this patient was diaphoretic, weak, had an irregular pulse or an arrythmia (he was tachycardic, he did not have a rhythm problem)then I would have waited for an ambulance. If he was at risk of stroke or I thought that stenosis was likely, I would have checked for bruits (possibly but as a paramedic and not an ECP, unlikely).<br /><br />His pulse was 180 transiently and my probe isn't the most accurate in the world, so on palpation and with a secondary check I could tell that he was settling.<br /><br />He was stable so that meant I could reasonably predict that he would remain so for the journey and not be detained unnecessarily waiting for an ambulance. And here's my point - you would have seen a few jobs where someone has died for lack of an ambulance because none were available as the direct result of being tied up on non-emergent calls - calls that were not immediately life-threatening. A tachycardia that resolves and settles is NOT immediately life-threatenng. Only those who believe that we should cover our backs so much that every call goes by ambulance would stick to the notion that my actions were problematic.<br /><br />A Red3 drunk person is probably not life-threatened, you'd agree but the whole 'they might choke on their vomit and die' argument forces us into a corner and we have to run on them as if they are having a coronary. We therefore take the same level of clinical risk when we simply pop them into the back of an ambulance without a routine ECG to check for a possible cardiac problem we just couldn't predict.<br /><br />And no, he didn't get a cannula because (and you can check this) we are now being told that KVO cannulae are not to be sited unless absolutely necessary.<br /><br />This young man's clinical presentation was benign. He was calm and without pain. His hypertension was not a diagnosed condition - he just assumed he was because he'd been told by someone else.<br /><br />I make clinical judgments that are calculated risks, some of which are close calls in others' opinions but I strive not to make 'silly' risks. I do NOT think I am always right but I always think of the patient first. If you are an ECP, you are expected to decide on the correct pathway for a patient. Your judgment will be tested too and what you see as high risk may not be to someone else. It depends on age, experience and capacity. Of all the calls I attend that I have written about, how many would you say were as 'risky' as you assume this one was? This is all about perception. I can see your point of view but I am not you and I don't live like that; I use MY on scene judgment when I am working alone and I trust my judgment.<br /><br />Finally, and hopefully to end this discussion. Every patient that I convey in such circumstances is asked at least THREE times if they agree to my taking them in the car when there is no ambulance available and I have explained the pros and cons of it. If they are not happy or in doubt, then I will wait. My PRF always includes a note about me conveying patients and why I did it. The devil is in the detail.Xfhttps://www.blogger.com/profile/08189044083128101123noreply@blogger.comtag:blogger.com,1999:blog-5498194182629204271.post-1434602339463130172010-02-02T20:12:34.816+00:002010-02-02T20:12:34.816+00:00XF
Thank you very much for your reply - I hoped y...XF<br /><br />Thank you very much for your reply - I hoped you would.<br /><br />Just a few points to clarify my comment:<br /><br />As a clinician I can ONLY comment on what you have divulged. I can appreciate that we as clinicians are duty bound to protect our patients thus I find it slightly odd that you state my "opinion on whether or not a professional clinician is irresponsible or not should be tempered with a broader picture of what went on at the time".<br /><br />I am not privvy to all information therefore can only comment on what's given!<br /><br />I mentioned listening for bruits as you did not specify in which way you had reduced the patient's heart rate. Listening for bruits is part of a cardiac assessment. <br /><br />So, an ambulance was not assigned? Ok, that can often be the nature of the beast so I ask the next question - Why were you so keen for a "stable" patient to be seen by a Dr so quickly? What difference would 10 minutes have made to a "stable" patient? The very fact that the patient had, a short time before, a heart rate that even if he was recovering from an erotic dream, was still, lets admit, a little too high to have been caused by an erotic dream alone? At the same time you cannot exclude the fact that it may have been cardiac related (despite a 12 lead ECG) or hyperthyroidism or something else. Despite the hospital only being 2 minutes away ( aren't they all?) by conveying in your car this still leaves you unable to deal with the patient in a safe environment, appropriately, adequately and dare I say it, quickly enough. I also ask if you cannulated the patient? <br /><br />There are calculated risks and there are silly risks. You and I know what would happen to you if that patient arrested in the back of your car and subsequently died. Your feet would not have touched the floor - this is a totally different risk from that of a non conveyed.<br /><br />I appreciate that as a diary it should be read without looking too far into the details however, I will reiterate to you again I can only comment on what you put in your diary and base my opinion as such. <br /><br />I did not mean this in any way to be a personal attack on your clinical decision making skills. I was concerned and intrigued about your treatment of that patient. I am merely trying to protect a fellow clinician.<br /><br /> I will add as a final point that your diary is a public domain and therefore your diary is open to critique or opinion.<br /><br /><br />SLMAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-5498194182629204271.post-10617297998233554622010-02-02T19:30:40.600+00:002010-02-02T19:30:40.600+00:00You should get some Sealskins gore-tex socks!You should get some Sealskins gore-tex socks!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-5498194182629204271.post-83465147467726563892010-02-01T17:54:09.181+00:002010-02-01T17:54:09.181+00:00SLM
I don't mind criticism but your opinion o...SLM<br /><br />I don't mind criticism but your opinion on whether or not a professional clinician is irresponsible or not should be tempered with a broader picture of what went on at the time, most of which I cannot divulge for obvious reasons.<br /><br />Young people can in fact have very high pulse rates every now and then without a cardiac cause. Overactive thyroid, for example. And if you read what I wrote, you will see that I did not say that 180bpm was USUAL.<br /><br />No, I did not perform a Carotid Artery Bruits check because it was irrelevant and his exercises involved Valsalva, which worked. He had no chest pain at all and was recovering from a vivid erotic dream when the whole thing started. This is not the first time I have come across such a case but there is a point that you should consider.<br /><br />There was no ambulance assigned to this. I was it. The hospital was literally 2 minutes away and I would probably have waited more than ten for an ambulance if I could get one. He was more at risk just staying there than coming with me - someone who could deal with any eventuality that occured en route. He got seen by a doctor in less time that way.<br /><br />As for risk-taking with patients. That doesn't happen with me. I use clinical judgment. I could leave a perfectly healthy person with a cough at home and still find myself in trouble because he died later on of something completely unforseen. Every clinicain...EVERY one of them, takes the same risk every day of their careers. But delaying appropriate hospital treatment with a stable patient is just plain silly and possibly irresponsible.<br /><br />It's a diary and it should be read without looking too far into the details and numbers I post - remember I am duty bound to conceal ALL patient-relevant facts that could identify them as best I can. That means things get changed, numbers, locations, names and other details get messed with.Xfhttps://www.blogger.com/profile/08189044083128101123noreply@blogger.comtag:blogger.com,1999:blog-5498194182629204271.post-33632231384483880672010-02-01T11:51:48.314+00:002010-02-01T11:51:48.314+00:00As a frequent visitor to your blog I was somewhat ...As a frequent visitor to your blog I was somewhat surprised and a little concerned at this latest entry.<br /><br />I find that fact that you conveyed a patient who had previously been in a cardiac arrythmia and still a high risk patient quite frankly, irresponsible. Not to mention dangerous and certainly not in the best interests of the patient.<br /><br />You say that his current heart rate (after a few careful excersises - valsaver? Did you listen for bruits of the carotids?) had reduced to 111 bpm and he had no pertinent chest pain. However, the fact that this patient has hypertension and a potential heart problem appears to go unnoticed. Incidentally, it IS unusual for ANY person to have a heart rate that hits 180 bpm regardless of cause.<br /><br />As a paramedic/emergency care practioner I would not leave myself open to loss of registration or the patient open to innapropriate care by conveying such a high risk patient in a car regardless of how close the hospital is.<br /><br />I don't wish this comment to be a slight on your clinical judgement per se. I'm just surprised that you left yourself wide open to all sorts of potential aggro.<br /><br />Meanwhile, keep up the blog - makes for great reading :)<br /><br />SLMAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-5498194182629204271.post-42447735566021968932010-01-27T21:12:29.608+00:002010-01-27T21:12:29.608+00:00'She gets scraped off the road and into an amb...'She gets scraped off the road and into an ambulance where fluids help her falling BP to recover, although her dignity never will.'<br /><br />I see this quite often on campus for the Students' Union events I help cover (thought undoubtably not as often as you do). It made me think: the first impression I get of an alarming number of people I meet for the first time in a professional capacity is one of drink, vomit, undignified and 'He/She's only had a couple'.<br /><br /><br />And people ask me why I'm Tee-Total...Anonymousnoreply@blogger.com