Posted by: medicblog999 | May 2, 2009

Over to you – Post 1, The conclusion!

Firstly, my apologies for the delay in getting the post up. Those pesky patients keep ringing 999 and make me have to keep logging off the computer!!
Also those astute among you will have noticed that even though I said I was going to post “over to you” stories on a Saturday and Sunday, I have started the first one on a Friday and Saturday. This is purely down to my working both day shifts and night shifts this week and having a completely messed up body clock.

Anyway, back to Mike, for the conclusion of “The Refusal”


Part 2

Your Practice:

The hardest part of being a new paramedic is trying to decide what type of medic you want to be and how you’re going to practice.  Many EMS blogs address this and there’s a ton of good advice out there.  For me, I have always tried to model myself after medics I’ve admired- you know the type; great with people, can diagnose from across the room, never miss an IV and haven’t let the job grind them down, etc. One of the most memorable was my first partner over 20 years ago who told me this:

“set a standard of practice for yourself that you are comfortable with  and stick to it on every call”

Gradually over the years, after watching how others do it, you become comfortable with your own approach to every call, adjusting as new treatments and equipment come along, but trying to be consistent with that personal standard you’ve set yourself.

For what it’s worth, mine incorporates such things as;

  • Beware of the “drunk” patient, they’re just waiting to make a fool of you.
  • Make the same decision in the last 30 minutes of your shift as you    would in the first.
  • If at all possible do as complete a physical exam as you can on all your patients – no-brainer right, but how many medics have you seen place a drunk on the bench seat and done the EMS taxi to the ER without even taking a pulse.
  • Be humble; there are calls out there just waiting to humiliate the best Paramedic in the world.
  • Try to have some empathy; it could be you in that nursing home bed in 40 years
  • You’re paid to be civil and professional with everyone but can pick the people you’re nice to.
  • Remember it’s the no-hauls and refusals that can trip you up.
  •  Etc, etc

The Answer:

A previous service (in another state) I worked for had adopted a policy on what it called “High Risk Refusals”.  It required medics to be extra vigilant with a certain subset of patients who refuse transport.  These included:

– Any patients over 55

– Any patient with either an active or status post chief complaint of chest pain, dyspnea or loss of consciousness (ie; wake up diabetics, seizures, syncopal episodes, etc )

 It required clearance from a supervisor and a complete ALS exam including EKG, SaO2 and blood sugar as well as regular vital signs before a refusal could be signed.

Although this seemed a little onerous at the time it made sense from a medico-legal standpoint so I adopted it into my practice where it just became routine, so routine in fact that I didn’t even consciously think about it any more….that’s why I had my partner get a strip.  I would like to think that some clinical sixth sense made me want it but I’d be lying. 

I think it was just that desire to try to be consistent


Personally, in Mikes post the one part that I am going to take from it is:

Make the same decision in the last 30 minutes of your shift as you would in the first

Ive never really thought of it that way. I try to be consistent, like Mike, but that is a great one liner bit of advice to dish out to all the newbies (and some of the more experienced staff too!).

Big thanks go to Mike for being the first (of hopefully many) guest bloggers on Medic999. I hope you have all enjoyed reading another perspective, and Mike, I hope you have enjoyed the experience and the feedback. Please feel free to submit some more whenever you want!

ALSO – I am going on holiday in 9 days – going to Spain for two weeks (swine flu allowing of course!) Mrs Medic999 has stated that I AM NOT TO BLOG whilst I am away, on pain of several very painful deaths! This leaves a two week gap which I would love to fill with guest bloggers, so If you fancy having a bash, get those stories in – anything to do with prehospital or emergency care, from any perspective.

Anyway, I guess I should go and write my own blog post for tommorow now!

See ya.


  1. I was a bit concerned about a call I got as a CFR today. I was sent to a bloke in his 70s who’d had a siezure.

    Couldn’t find the address at first (the emergency call people who’d called 999 had it round their necks!) but was directed by a neighbour.

    I’d called Control for more info, but they wanted to stand me down as it had been triaged down to Cat C. I pointed out that I was very close, so they let me go in (closely followed by a crew).

    The patient was still unconscious. This must have been 20-25 minutes after the siezurte started, as the neighbour present faffed around getting advice from someone else before pulling the cord to the emergency centre, who then had to call 999 etc.

    He was still twitching a bit in his limbs, though the main fit had subsided.

    He did not respond to voice, nor when shaken, though he did have a (slow) response to pain.

    Some 40 minutes after the siezure started (and at least 20 minutes after the call had been downgraded to Cat C), the patient was heavily post-ictal and in no condition to be left alone – or even with well-meaning but inexperienced neighbours.

    Yes, the patient had a history of epilepsy, but I still consider the downgrading to Cat C as erroneous.

    I reckon that some weight must be put on the number of people the info passed through.

    Obs of PT –> untrained neighbour –> emergency call centre –> triage nurse.

    I’m glad I insisted.

    (Mind you, I also went to a call a while back when the young patient’s parents had called back for “Not required” just as I arrived, but I knocked anyway. I ended up calling it back to Control, and an ECP came, eventually prescribing for the PT.)

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