ny10570

Do you really think the problem is on PD?? Cracking down on the users doesn't have any affect on this crap. All it does is tie up cops, courts and jails while someone else is out there getting high. Look at how completely ineffective the Rockefellar era drug laws were at detering drug use.

http://www.vententersearch.com/?paged=2
Scroll down a bit, some good photos of hidden rooms that are relatively common.

Do you really think the problem is on PD?? Cracking down on the users doesn't have any affect on this crap. All it does is tie up cops, courts and jails while someone else is out there getting high. Look at how completely ineffective the Rockefellar era drug laws were at detering drug use.

Do you really think the problem is on PD?? Cracking down on the users doesn't have any affect on this crap. All it does is tie up cops, courts and jails while someone else is out there getting high. Look at how completely ineffective the Rockefellar era drug laws were at detering drug use.

First and foremost, it is not a bad batch of heroin going around, but an extremely good batch cooked with synthetic opioids, most commonly phentanyl. Narcan is absolutely dangerous in the wrong hands. The jackass medic that uses it just to ruin the high or deliver a vomiting patient to the ER is even more dangerous than the EMT who dumps 2mg into the junkie who's just nodding out. Narcan is not there to assist in obtaining a patient history, it is used to restore respiratory effort. So now this BLS crew is doing a phenomenal job of ventilations. One member has the seal and the other is providing ventilations. After administering 2mg of Narcan IN the patient, before becoming fully awake begins vomiting. These two EMTs, used to this pt not being exactly compliant with ventilations since he's not dead, just doped up to the gills; continue ventilations until they've filled his lungs with stomach contents. Eliminate the narcan and this is a scene I've witnessed a couple of times. These patients need quality ventilations by competent rescuers.
More often than not good CPR alone is enough to get back opioid arrest because that main affect is respiratory. Correcting the hypoxia and hypercarbia is what revives your asystolic opioid arrest.
IN, IV, and IM narcan are the same drug. IN and IV systemic distribution rates are similar in the lab. However apnea, nasal congestion, and structural damage to the turbinates all result in decreased absorption during nasal administration. Nasal administration works great with someone with clear sinuses that can inhale for you. Apneic junkie who's probably snorted more things than you care to think about therefore isn't going to absorb so much. My preference is IV, IM, then IN.
A more pressing topic in my world is the need to transport opioid over doses. There was a study out of San Diego in the 90's and another from the midwest more recently where zero patients treated by EMS with narcan for opioid overdose were found to have died in the ensuing 12 hours. While the emergence of synthetic opioids may impact this, as of now no one can demonstrate harm in offering overdose patients an option to RMA.

I love all this hate on the idiots who's own actions bring us to their door. People who drive to fast, don't buckle up, or drive under the influence all get our care. People getting lost on mountains, getting into fights, and all sorts of other stupid actions get an eager response from us. Heart disease is the biggest preventable killer in emergency services. Look around and see all the members who are a bit more than an ideal weight. Should they all go piss off because of their affinity for fried food and cold beer? Yeah, the regular abuse of the system caused by heroin addicts, alcoholics, meth addicts, etc is frustrating. However WE CAUSE THE ABUSE. The intox sleeping on the corner usually doesn't want to go to the ER. The junkie who has nodded out didn't intend to end up in the ER and unless they're not breathing do not need the ER. Data analyses from two different systems shows that after administering narcan these patients just go back to doing what they were doing. Taking them to the ER ends up with the same result. There's not an addict alive that doesn't know where they can get help. Dragging them to the ER isn't going to change their behavior and if they're alert and oriented taking them to the ER can be construed as kidnapping.

First and foremost, it is not a bad batch of heroin going around, but an extremely good batch cooked with synthetic opioids, most commonly phentanyl. Narcan is absolutely dangerous in the wrong hands. The jackass medic that uses it just to ruin the high or deliver a vomiting patient to the ER is even more dangerous than the EMT who dumps 2mg into the junkie who's just nodding out. Narcan is not there to assist in obtaining a patient history, it is used to restore respiratory effort. So now this BLS crew is doing a phenomenal job of ventilations. One member has the seal and the other is providing ventilations. After administering 2mg of Narcan IN the patient, before becoming fully awake begins vomiting. These two EMTs, used to this pt not being exactly compliant with ventilations since he's not dead, just doped up to the gills; continue ventilations until they've filled his lungs with stomach contents. Eliminate the narcan and this is a scene I've witnessed a couple of times. These patients need quality ventilations by competent rescuers.
More often than not good CPR alone is enough to get back opioid arrest because that main affect is respiratory. Correcting the hypoxia and hypercarbia is what revives your asystolic opioid arrest.
IN, IV, and IM narcan are the same drug. IN and IV systemic distribution rates are similar in the lab. However apnea, nasal congestion, and structural damage to the turbinates all result in decreased absorption during nasal administration. Nasal administration works great with someone with clear sinuses that can inhale for you. Apneic junkie who's probably snorted more things than you care to think about therefore isn't going to absorb so much. My preference is IV, IM, then IN.
A more pressing topic in my world is the need to transport opioid over doses. There was a study out of San Diego in the 90's and another from the midwest more recently where zero patients treated by EMS with narcan for opioid overdose were found to have died in the ensuing 12 hours. While the emergence of synthetic opioids may impact this, as of now no one can demonstrate harm in offering overdose patients an option to RMA.

When done properly these homemade hydrogen sulfide suicide kits works very well. Ideally the victim chooses a secure enclosed space, clearly identifies the hazardous area, initiates the reaction, and calls 911. The fastest response isn't going to save this person. The catch is what happens when you catch them before they're ready for you. For instance the victim happened to choose your favorite mid afternoon nap spot for their suicide and you stumble upon it just as its getting going. H2S is extremely flammable and heavier than air. If you do decide to break the window and rescue them, that car will still be filled with H2S. At concentrations these homemade devices are fully capable of producing, a single breath is enough to be fatal. Keep in mind waiting for hazmat assures the patient will die. On the other hand if they're already not breathing they're too far gone for you to help. Treatments in the field are going to be limited to symptom management, to combat he bronchospasm, pulmonary edema, respiratory failure and cardiovascular collapse. The only antidotes I'm aware of aren't carried around here, amyl nitrite ('poppers' for all the party people on here) or sodium sulfite.

By that argument, we can't RMA anyone eating a Big Mac. Letting someone die solves our problems, it does not solve the patient's problems. EMS absolutely must leave their personal prejudices at the station door. Our job is to improve outcomes, not to pass judgement. That's a different job that pays much more.
As it was described to me many years ago, anyone who has overdosed and has regained consciousness prior to intervention is a candidate for refusal if they so desire. Anyone who has had interventions needs to be seen in an ED. Are we not supposed to titrate the patient back to breathing and airway patency without making them mean and ugly?

http://www.vententersearch.com/?paged=2
Scroll down a bit, some good photos of hidden rooms that are relatively common.

I'm not really understanding why some of you still after very good input in posts from respected members in the profession on the street, are making this out to be so much more then it needs to be. Every type of situation can and will fall in a gray area. As I said in my initial post...if you are flagged down and stop...rapidly triage the situation and act accordingly. Notify your dispatching center of the situation and what you need in order to handle the situation overall...whether it be you control the situation you came across and have them send a unit and you explain the situation to the parties...or you stay at the one you are at and have another unit dispatched to your initial call and document a PCR for both incidents. There is no one exact answer here...attorney or not. Use your brains and stop the chicken little sky is falling with worries of litigation. Use your best judgement and document accordingly...unless you are extremely negligent you will have no worries lawsuit or not. And here is other food for thought...if you have multiple patients...do you not triage? And if you are the lone unit or even person on scene...do you not often have to leave patients to go to another and may not get any further if you have a critical injury that you can intervene and save or stabilize them? Similar instance...and again document document document. I can tell you there are times where enroute to one call, that another call will drop and be along my response route and have people waiving thinking I'm coming to them...sometimes I can stop quickly to tell them...other times I've seen them too late to safely stop and keep going. It happens. Relax...do your job the rest will come along.

If you are flagged, you are flagged. That is now your patient. What if you were on scene at a skinned knee and hear a call go out across town for that confirmed arrest? You're still obligated to either transport or RMA that patient.
You have no legal liability in that case unless you were to delay notification that you were flagged. What if that CVA were actually Bells Palsy and your general malaise was a massive MI? You assessed the sick, blew it off as just being a sick and hurried on to the stroke. Now you are in trouble because YOU denied the sick definitive care in a timely manner. If you get into a wreck on the way to call, its not your fault the patient didn't get the ambulance. If you stop for a sandwich then it is your fault the patient didn't get their ambulance.
If you're transporting a patient then once again the patient you have is your priority. if they're stable feel free to get involved. If they're unstable document accordingly. Accurately describe the situation over the air. Continue on to the ER. If stopping will cause harm to the patient in the bus, you must continue to the ER.

Now there's a statement worthy of a tatoo....

As I read through the comments, I couldn't help but realize that many people said the same thing. Education is key. Just the other night I went on a trouble breathing call, pt was quite elderly. She provided no medical history, stated that she had no medical history. And that is what the EMT wrote on his PCR. When we got to the hospital and he heard me give my ALS report to the RN, the EMT was obviously confused. He asked me how I knew the patient had CHF because she didn't say she had a history of such. EMT class use to focus on the pathophysiology of disease. It forced students to looks at SIGN and SYMPTOMS and put the puzzle together. Now, EMT has been dumb-downed so much that it is simply "You have trouble breathing? Here is oxygen." EMTs need to take an initiative to learn beyond their textbook and gather more information to supplement their career. Perhaps then the EMT on our call would have noticed her "CABG" scar, slightly swollen ankles, lasix and betablocker medications and been able to put some information together. Granted her lung sounds were clear and equal bilaterally, but not every call is textbook - - thinking is essential. Education is imperative.

If you are flagged, you are flagged. That is now your patient. What if you were on scene at a skinned knee and hear a call go out across town for that confirmed arrest? You're still obligated to either transport or RMA that patient.
You have no legal liability in that case unless you were to delay notification that you were flagged. What if that CVA were actually Bells Palsy and your general malaise was a massive MI? You assessed the sick, blew it off as just being a sick and hurried on to the stroke. Now you are in trouble because YOU denied the sick definitive care in a timely manner. If you get into a wreck on the way to call, its not your fault the patient didn't get the ambulance. If you stop for a sandwich then it is your fault the patient didn't get their ambulance.
If you're transporting a patient then once again the patient you have is your priority. if they're stable feel free to get involved. If they're unstable document accordingly. Accurately describe the situation over the air. Continue on to the ER. If stopping will cause harm to the patient in the bus, you must continue to the ER.

Those agencies are long gone. They merged and became F U Ambulance Service and exist everywhere. Nothing like the medic running for his flycar before we even got inside the ER so he could jump on the hot call coming in.

This is an issue for the agency to handle. The liability here doesn't apply to the individual units as long as they're operating according to agency guidelines.

He lost a few days pay and spent several weeks on a patient care restriction because he was wrong. He may have also been reprimanded by the state but I'm not sure.
The gist of the argument was that because we really don't know what we have till we actually get there we have to treat the patient we have in front of is. If you're on scene with a booboo and you hear a cardiac arrest get dispatched a few block away can you just leave the booboo for the arrest? Thats the way the state looks at it. It doesn;t matter where you were going, you are now on scene with your patient.

My ambulance has been parked on 163 & Westchester, Southern & 167, and 149 & Union in the Bronx for many full moons as a medic and I was scattered all over the north Bronx as an EMT. I've done my share of shenanigans filled evenings with EDPs, PCP abusers and the latest inductees to the knife and gun club. There is not a correlation between the moon and the stupid.
I'm going to go with selective memory to explain this one. The big incidents or crazy nights that happen on or near a full moon reinforce a previously held notion. This causes a stronger emotional response and makes a stronger memory. Then years later when you reflect back on all your "bilat 14g's" all those events near a full moon are clearer in your mind. The research is there. Read for yourself, The Google knows all...

I do know the outcome of one abandonment case from many years ago. A Chicago FD EMS crew was sued for abandonment and wrongful death after a pediatric asthmatic patient died and they "didn't" respond. In a nutshell, the call was in a housing project and the crew was harassed and menaced upon arriving. When they got to the building, rocks/bottles and other air mail were thrown at them from the rooftop. They retreated, got back to the ambulance and left the area to await PD support. They were sued (and if I remember correctly the city didn't indemnify them and terminated or suspended them). The court ruled that there was no abandonment because they had not made patient contact and there was no wrongful death because they retreated for their own safety and returned once the scene was safe. It was the child's pre-existing medical condition that resulted in his or her death, not the actions or inactions of the EMS crew.
So, that's one case where the decision proves the point - they're not your patient until you make contact with them.
How do you know the cardiac arrest is a cardiac arrest and not a sleeping drunk or a non-viable DOA? If you're flagged down for a patient, I think you have to tend to that patient and get the other job reassigned.
Thanks, ny10570, very well said.
alsfirefighter also made the point very well.
Great thread!

First off... I think this is a great discussion topic and would like to see posts by some of the most experienced members and chiefs for their experiences.
It is some what of a grey area, however, one clear rule is that once patient contact has been made, you are bound to that patient (except for transfer of care to same cert or higher). So, if you are transporting a pt to the ER, you may not stop for an MVA. You should call the accident into dispatch to avoid potential liability. Plus your service would get a very bad name if it came out that an EMS crew failed to report an MVA while driving by it (even w/ a pt in the back).
Just remember that for a lawyer to prove BASIC negligence, they must prove 4 elements:
1. The Plaintiff suffered injuries
2. The Defendant owed a duty to the plaintiff
3. The Defendant breached that duty
4. The Defendant's beach was the actual and proximate cause of the Plaintiff's injuries
Each element must be proven for a cause of action to continue to a jury.
Although you did not cause the actual injury (i.e. the MVA), the law recognizes a duty to act based on reasonable foreseeability that injury will occur.
The law views duty to act cases as "difficult" duty cases and many items have to proven as a matter of law. That is, the judge decides if the duty existed. It becomes a factual dispute for the jury when the knowledge of the defendants comes into question (i.e. did the crew know that they had a duty to act but still failed to do so).
After thinking about this question for some time, everything relates back to your EMT-B training. Remember those early sections on duty to act? When you are in uniform you have a duty to render care. You have a duty to not abandon. ETC...
The most important things I remember hearing during this section of training was the use of discretion and do no harm...
Just act in good faith and be true patient advocates. It will be very hard for a lawyer to go after you for most of the situations posted (except for the one when you have a pt and are en route to the hospital) so long as you exercise sound discretion. You can "What If" scenarios ALL DAY! Experience is the BEST way to learn the most appropriate course of action.
(NOTE: This post should not be relied upon for legal advice. It is simply to add to an educational discussion. Please consult a lawyer in your respective jurisdiction for any/all legal advice.)

You are to render aid at the emergency you have, not the emergency you might have. It doesn't matter what you are going to you, if you are presented with a patient requesting help you are to help that patient. I'm just an lowly field paramedic but this is coming from a former partner's patient abandonment hearings after he ignored the civilian flagging him for the same old drunk on the same old corner while he was headed to a cardiac arrest.
In the first scenario the chest pain patient is not your patient until you get on scene. The could no more hold you responsible for getting flagged than they could jam you for getting into an accident on the way. Now failing to respond or intentionally delaying your response is a different matter. Your second scenario is the reason why the law does not differentiate between call types of the potential patient. There may very well not even be a patient at the scene, but there is definitely a patient in front of you at the accident or whatever you've been flagged for.

My ambulance has been parked on 163 & Westchester, Southern & 167, and 149 & Union in the Bronx for many full moons as a medic and I was scattered all over the north Bronx as an EMT. I've done my share of shenanigans filled evenings with EDPs, PCP abusers and the latest inductees to the knife and gun club. There is not a correlation between the moon and the stupid.
I'm going to go with selective memory to explain this one. The big incidents or crazy nights that happen on or near a full moon reinforce a previously held notion. This causes a stronger emotional response and makes a stronger memory. Then years later when you reflect back on all your "bilat 14g's" all those events near a full moon are clearer in your mind. The research is there. Read for yourself, The Google knows all...

Another great example of why all the blue lights, LEDs, and reflective stripping aren't going to save your butt. We're plenty visible, but if the idiot behind the wheel isn't looking it doesn't matter.

I love that "this will not affect service garbage. If thats true than you've been ripping off the taxpayers for years! So either these officials are terrible managers or flat out liars.