Posted by: medicblog999 | September 26, 2010

A Medic “Mortality Allowance”?

Sometimes a thought pops into my mind from absolutely no where. Sometimes they are sparked by a quick visual cue. This is one of those times.

First a disclaimer – This doesn’t mean that I believe that what I am suggesting is right, it’s just a thought that might be interesting to share and hear your views on.

I was sitting in my ambulance today and saw a patient getting taken out from A&E whom I had brought in a couple of hours before. The details of his condition are unimportant, other than to say I was 90% sure that he didn’t need to go into hospital for his fairly minor injury, but the other 10% won and as always, I aired on the side of caution and took him in.

As he was pushed past my ambulance in a wheelchair to be taken back home, I quickly wondered if I should have left him there in the first place? After all, there was apparently no need for hospital admission or treatment. If I had left him at home we would have been available for a further emergency and could have freed up a bed in the A&E department.

So, what made me bring him in?

I am happy to leave people at home if I am comfortable that my clinical decision is both sound AND safe. If I ever cannot get to that position of comfort then the patient goes to hospital.

The question to ask however, is how many of these patients that are borderline ‘stay at home’ patients needed further treatment in hospital or even an admission? I would suggest that the number would be very small.

Now for the moral / ethical question….

Doctors apparently have some level of accepted mortality rates with their treatment and assessments. Patients sometimes die; usually expected with a clear clinical course leading to their death, but sometimes when things need to be looked at a little closer in forums such as Mortality & Morbidity review panels. These are opportunities to learn from times when things haven’t gone to plan and to try and prevent reoccurrences of potentially avoidable deaths.

It doesn’t mean however, that from then on, all patients similar to the one who died will get over treated ‘just in case’.

In EMS we try to achieve perfection in what we do. As a profession we are historically risk averse and do whatever we can to avoid litigation, which is why everyone with a little neck pain following an RTC is collared and boarded; why anyone following a high MOI incident gets the full trauma work up, even if they appear uninjured and well.

Now think what our job what look like if it was accepted that some patients may slip through the net. Not through negligence, but through a natural disease process that was not present at the time of the assessment by the paramedic.

Should paramedics have an acceptable mortality rate?

Not in the sense of a certain amount of deaths that he or she is allowed to have before anyone looks into things, more like a general acceptance that sometimes, people can deteriorate from the time that a paramedic assesses them as suitable to not be transported to hospital.

Now, before you jump in, stop…..think this through, then let me know your opinion

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Responses

  1. If we do our job to the best of our ability, or to the ability that is considered acceptable by means of what other, similarly trained people would do, and we do not transport somebody and their condition deteriorates, and they die, we have done what we are trained to do, and are ethically and morally obligated to do. If you do that, you should be able to sleep an night knowing that nature has taken its course, and you should have no regrets, or legal repercussions.

  2. How bizzare…. I was having a discussion with my better half a couple of hours ago which was along very similar lines…

    We were discussing how a new response model is being trialled in London and, while I hope it will work, there needs to be an understanding that sometimes, things go wrong.

    Sometimes, that patient that you have fully assessed, has no red flag symptoms, obs are stable and has no reason to urgently need to go to hospital that you may arrange an A+E support crew to come and collect within 2 hours goes and dies before the A+E crew get there. Something odd happens that you couldn’t have foreseen, expected or predicted.

    It is similar to my car – went in for MOT, had things done, all checked, all ok, working fine. Next day, battery dies. Totally unrelated. Nothing the garage could do. They were not at fault. All was working fine before. It just chose that moment, just after having been seen by a mechanic, to die on me (and cost me even more money in the same week!!). It happens.

    However, something that I think is key is unless there is belief from road staff that should freak occurances like this happen, then the old school thinking of “just take them to hospital” will never change. We need to have belief in ourselves but also belief that should the unthinkable happen that you will not be the centre of a witch hunt. Without that belief, people will continue to protect their job / registration / career by taking people to hospital when. in all likelyhood they don’t need to be there.

    I am also one for not leaving people at home unless I am 100% sure of my descision. But even when I am 100% sure, there is still that nagging “what if” scenario that lurks in the back of my head. This is why I ALWAYS make a point of saying AND documenting that “Should anything change or you become concerned by anything, please phone back”. With proper documentation, proper assesments, and proper trust in those we work for, we should be able to leave more people at home, or at the very least, leave them at home waiting for a non-A+E vehicle to come and take them in within a few hours time.

    So, do I think Paramedics should have an “Acceptable Mortality Rate” – well sort of but I don’t like the term “acceptable”. It is never “acceptable” that someone dies when it could have been avoided. However, it may happen and thus be UNDERSTANDABLE and, while regretable, I don’t think people should be hounded for it – they will probably need support more than anything because if they are anything like me they will be feeling quite sh1t about it anyway. I believe that a Mortality and Morbidity type forum to discuss, debrief and learn from each case would be a fantastic idea, a way of learning from any mistakes, if there are indeed any, and ensuring that things never happen in vain. TBH, feedback in general from your patients is lacking in EMS – perhaps this is a small peice of a bigger puzzle that needs looking at….

  3. I think people who work in emergency care already accept this! Yes, I think paramedics are forced to transport a lot of patients “just in case” and I think a lot of these people get sent home very quickly from A&E… If they then deteriorate it just becomes the A&E dept that takes the flak not the paramedic. I don’t think EITHER should. Patients can deteriorate quickly, and we cannot allow for that. For example, in A&E, elderly pt in majors for UTI (pt is asymptomatic though, so I don’t know why pt came in), we were about to send this pt home, just waiting for 1 more blood result, then we were going to arrange transport for him to return home. Then this pt went into cardiac arrest. Had he done that even 30-60 mins later, he would have been at home and probably would have died. The papers would have picked up in him being sent home from A&E, and we’d get the flak. You cannot predict what is going to happen to someone. And taking pts you don’t really think need hospital treatment is silly, and adds to the burden of A&E depts. Also, transporting these pts makes them think that it’s appropriate to call 999 for whatever they called 999 for, which it quite probably wasn’t, yes?

  4. One of the things that I feel holds paramedics back in their training, studying, and practice, is the mystical “What If?”. Up until very recently, it was drilled into both new recruits as well as seasoned medics that you take everyone to hospital. That way, you’re never held responsible should anything go wrong.
    However, any EMS person worth their salt, hates taking people to hospital unless it really is necessary.
    Recently, ambulance services as well as A&E departments have started to look at other options. How do we keep people out of hospital, rather than drag them in. But this will have to mean a change of attitude from all concerned and on many fronts.
    One fact will have to be accepted by all concerned. It will happen.
    A patient will be left at home, and through nothing remotely resembling negligence, or even through a turn of events completely unconnected with the original call, will sadly die.
    It might be the patient in their late 90s, it might be the terminally ill 40 year old, and it might just be a normally healthy patient with flu-like symptoms who then takes a rapid turn for the worst.
    And this is where the challenge will begin. Paramedics (and EMTs) will have to be aware of the possibility, but will of course do all that they can to guarantee they have ensured the safety and wellbeing of their patient as they present to them at the time. They will have to stress the importance of calling again for an ambulance should any serious changes occur. But they will be confident that they’ve left someone at home because it is safe to do so.
    The families will have to accept that the staff who visited did their best, assessed the patient to the highest level, and gave the most appropriate treatment, guidance, and advice.

    And the ambulance service (call them management if you will) will have to ensure that their staff are motivated enough, knowledgable enough, trained enough, practiced enough and confident enough in their decisions to ensure that all of the above is true.

    At the moment, the blame game is king. So it’s not “acceptable” to have ANY mortality rate.

    Frontline staff are scared of the thought of being the last ones to see the patient alive, as invariably it means a lengthy disciplinary process which has an inevitable conclusion of sanctions, rather than an investigation into the facts, support where necessary, and a way to learn and progress from what has happened.
    I don’t for one second sanction the thought that we should all be unaccountable for our actions – much the opposite. I’d like us all to be not only accountable for, but proud of our decisions and treatment.
    Rule 1 of medicine (in all its forms) – people die.
    Our aim is to prevent that – in the best way possible, whilst still accepting the fact that we can’t save everyone and that sometimes the unforseen occurs.
    But when it does, having ruled out negligence at all levels, there is always something there to learn. And that sort of mortality is, to a certain degree, acceptable.

  5. Mark,
    I thought about what you said and posted this:
    http://studentofparamedicine.blogspot.com/2010/09/you-want-to-do-what.html

  6. Damned if you do, damned if you don’t! Sometimes there are advantages in being an Amateur.:-)

    If a Paramedic is doing his/her job correctly, there will be some deaths at home. Even if you are the best pre-hospital carer in history, unless you have second-sight or the luck of the Devil, you are bound to make mistakes.

    Part of the reason for introducing Paramedics and Technicians was to get some decisions taken at the scene. I can remember (just) when “ambulancemen” were medical taxi drivers. Called to a patient, they would always transport if that’s what the patient or their family wanted. Sometimes they didn’t intend to listen anyway, just to transport.

    In those times, the patient didn’t die after being left at home as none were. However, other patients died as the service couldn’t get to them quickly enough – they were too busy transporting someone who didn’t need it.

    Paramedics need to be given the right to exercise their judgement, even if that judgement is wrong (very rarely). Those who get it wrong too frequently should be retrained, or fired if they were careless.

  7. I think that one of the biggest learning experiences a medical resident can go through is to have to present a case at an M&M. In front of their superiors and peers, they have to admit to a mistake (generally with poor patient outcomes) and explain what they could have done differently. It is a great educational experience. I would hope that EMS can adopt a similar stance on mistakes (not negligence mind you!) and present these cases as a teaching/education situation.

  8. I would think that any system with a “respond not convey” option would have to accept a certain level of… not necessarily “error,” but of morbidity and/or mortality.

    Problem is, the public we serve has a different idea.

  9. Saw this thread on a google site and thought it may be about bonus percentage from the local under takers……. Solo responders get 10%, full ambulance crew receives 15% from cardiac arrest jobs where there is no ROSC lol.
    On a serious note, i work for NWAS, and the management way of investigations is very aggressive, with the crew proved guilty before investigation taking place and the service apologising for alleged low standards of treatment before an outcome has been reached.


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