DAN Responds

[L13]

I'm curious on this. I've provided emergency oxygen on the beach to exactly two patients that I'd say "needed" oxygen (one IPO/IPE and one DCS, both diagnosed on the beach and confirmed by hospitals). I also gave it to a third that was just panicky and hyperventilating. None ended up being transported by ambulance.

I had a student call EMS for the IPO/IPE patient. EMTs (Fire Department) determined that she needed to go to the hospital, but because she was conscious and stable they recommended just driving her there. They wouldn't do an emergency transport in Fire Department ambulances, but if she hadn't had a friend willing to drive her they'd have called an ambulance.

In the DCS instance, I knew the patient was stable and figured the fastest route to the hospital was cutting out the Fire Department completely because they would have just delayed the treatment process and she was feeling better while on oxygen.

In my part of the world, ambulance personnel really aren't trained to do much. Fire departments have paramedics that are dispatched to more serious situations, but a standard fire crew often does initial assessment. Ambulances are also expensive and often not covered by insurance (at least as I recall).

So was it appropriate for these folks to be driven to the hospital by a friend instead of an ambulance? Seemed so at the time and still seems so to me.

Where they were, being driven by a friend WAS the right thing to do. But, without the 3 hour stop at the dive shop to grill steaks that they did.

 

[TravelGas]

Yes, drive them to the hospital, only in a scenario where a bus is not available to make the transport.

If the patient feels so strongly after getting a second opinion from the bus crew that they should be transported to be seen, then that's what RMAs (Refuse Medical Aid Form) are for. Then the liability is now on the patient and not on the crew. Bonus side points, if you make a transport that could have been made by a bus in a POV to save on insurance money, what do you do in a POV when your patient decides to go into Respiratory arrest followed by Cardiac arrest, but you lack the proper training, equipment and space in your vehicle to handle this situation properly and your patient dies? Patients can be conscious and stable, until they become unconscious and unstable, at the worst time. Or, instead of calling for a bus and getting your patient seen, you could just go and eat steak instead, followed by feelings of impending doom and panicked phone calls to save a life.

 

[VikingDives]

I'm curious on this. I've provided emergency oxygen on the beach to exactly two patients that I'd say "needed" oxygen (one IPO/IPE and one DCS, both diagnosed on the beach and confirmed by hospitals). I also gave it to a third that was just panicky and hyperventilating. None ended up being transported by ambulance.

I had a student call EMS for the IPO/IPE patient. EMTs (Fire Department) determined that she needed to go to the hospital, but because she was conscious and stable they recommended just driving her there. They wouldn't do an emergency transport in Fire Department ambulances, but if she hadn't had a friend willing to drive her they'd have called an ambulance.

In the DCS instance, I knew the patient was stable and figured the fastest route to the hospital was cutting out the Fire Department completely because they would have just delayed the treatment process and she was feeling better while on oxygen.

In my part of the world, ambulance personnel really aren't trained to do much. Fire departments have paramedics that are dispatched to more serious situations, but a standard fire crew often does initial assessment. Ambulances are also expensive and often not covered by insurance (at least as I recall).

So was it appropriate for these folks to be driven to the hospital by a friend instead of an ambulance? Seemed so at the time and still seems so to me.

Where do you live?

I've been told that Albuquerque has better ems than most cities, perhaps that's true.

Our fire fighters are emt-b trained, and there's usually an few -i's and paramedics on each run. The fd does at scene care and the patient is transported by private ambulance (99% of the time) with a paramedic in back.

The fd folks will tell you they're much better at stabilizing and at scene care, but they are poorer at transport and the private ambulance folks will tell you they're the opposite. . .

 

[Cthippo]

Leaving patients at scene or recommending transport by private vehicle is a normal part of EMS protocols if the crew on scene feels it is appropriate. I have been on lota of calls where we administered oxygen and a nebulizer, got the patient stabilized, and left them at home. Usually you see this with COPD or asthma where they just need a little oxygen to get over the hump and then they are fine.

Both of my partners have asthma and so I keep annoxygen bottle in the closet because annoxygen neb beats an air neb beats an inhaler. Seems like it gets used at least once a month, yet we almost never take them in.

Now, this is not for DCS, but also the patient gets a vote.

 

[TravelGas]

What you are describing is completely different than what actually happened. I said, call for the bus if possible, have crew assess PT., documentation, if PT. declines transport, then PT. RMA and Police witness it if possible. In this situation a POV, is not a substitute for an ALS bus. Yes, there are times where assessment and no transport by bus, or even at all, are appropriate.

This situation is not a frequent flyer call to a known address for Asmtha.
Given the PT: NOI, General Impression, altered mental status, age, vitals, LOC, dehydration, etc. We don't even know Woody's past Medical History, nor Medications at his age to potentially further complicate this. This PT. is clearly unstable. I am recommending transport, documenting the hell out of it and if they wish to RMA, that's fine me and my crew are covered, we force no one.
But, I highly doubt Woody RMA, given they tried to get a bus for a 2 mile transport from one Hospital to another and could not. Woody gladly would have gotten in the bus, if that was an option. Were you also going to give him IV to bring his BP up while you giving him O2, before you leave him at the location? I am sure their Medical Director and call review would love that. Lets also not overlook that Woody's condition did worsen both during and after Gus's Steak treatment, so leaving the PT at the location and or advising self transport was a bad idea.

 

[TravelGas]

Where do you live?

I've been told that Albuquerque has better ems than most cities, perhaps that's true.

Our fire fighters are emt-b trained, and there's usually an few -i's and paramedics on each run. The fd does at scene care and the patient is transported by private ambulance (99% of the time) with a paramedic in back.

The fd folks will tell you they're much better at stabilizing and at scene care, but they are poorer at transport and the private ambulance folks will tell you they're the opposite. . .

In NYC, FDNY FF respond to every call, in most cases arriving on scene before the bus. All FDNY FF are certified to CFR (Certified First Responder / ~50 hr. course) level at the Fire Academy and can give O2. Some FF who came over from the EMS side of the house or who volunteer somewhere, may have a higher level of training.

 

[crofrog]

What you are describing is completely different than what actually happened. I said, call for the bus if possible, have crew assess PT., documentation, if PT. declines transport, then PT. RMA and Police witness it if possible. In this situation a POV, is not a substitute for an ALS bus. Yes, there are times where assessment and no transport by bus, or even at all, are appropriate.

This situation is not a frequent flyer call to a known address for Asmtha.
Given the PT: NOI, General Impression, altered mental status, age, vitals, LOC, dehydration, etc. We don't even know Woody's past Medical History, nor Medications at his age to potentially further complicate this. This PT. is clearly unstable. I am recommending transport, documenting the hell out of it and if they wish to RMA, that's fine me and my crew are covered, we force no one.
But, I highly doubt Woody RMA, given they tried to get a bus for a 2 mile transport from one Hospital to another and could not. Woody gladly would have gotten in the bus, if that was an option. Were you also going to give him IV to bring his BP up while you giving him O2, before you leave him at the location? I am sure their Medical Director and call review would love that. Lets also not overlook that Woody's condition did worsen both during and after Gus's Steak treatment, so leaving the PT at the location and or advising self transport was a bad idea.

and this is applicable in the abacos?

 

[Cthippo]

What you are describing is completely different than what actually happened. I said, call for the bus if possible, have crew assess PT., documentation, if PT. declines transport, then PT. RMA and Police witness it if possible. In this situation a POV, is not a substitute for an ALS bus. Yes, there are times where assessment and no transport by bus, or even at all, are appropriate.

This situation is not a frequent flyer call to a known address for Asmtha.
Given the PT: NOI, General Impression, altered mental status, age, vitals, LOC, dehydration, etc. We don't even know Woody's past Medical History, nor Medications at his age to potentially further complicate this. This PT. is clearly unstable. I am recommending transport, documenting the hell out of it and if they wish to RMA, that's fine me and my crew are covered, we force no one.
But, I highly doubt Woody RMA, given they tried to get a bus for a 2 mile transport from one Hospital to another and could not. Woody gladly would have gotten in the bus, if that was an option. Were you also going to give him IV to bring his BP up while you giving him O2, before you leave him at the location? I am sure their Medical Director and call review would love that. Lets also not overlook that Woody's condition did worsen both during and after Gus's Steak treatment, so leaving the PT at the location and or advising self transport was a bad idea.

I agree, this isn't directly relevant to the situation. I was pushing back at the concept of "anyone needing oxygen needs emergency transport"

If Woody would have been my patient I would have encouraged rapid transport with an ALS intercept, but that presumes a system where ALS/BLS are available on scene and patiwnts recieve care regardless of ability to pay, which was also not the case where they were. Calling DAN for all dive related injuries is also in our county protocols, which I thinknis a nice touch.

 

[cerich]

I agree, this isn't directly relevant to the situation. I was pushing back at the concept of "anyone needing oxygen needs emergency transport"

If Woody would have been my patient I would have encouraged rapid transport with an ALS intercept, but that presumes a system where ALS/BLS are available on scene and patiwnts recieve care regardless of ability to pay, which was also not the case where they were. Calling DAN for all dive related injuries is also in our county protocols, which I thinknis a nice touch.

I am also going to push back on some folks that have asserted that Woody needed an IV for rehydration immediately as well. Until IPE is ruled out, an IV could harm not help (oxygen is good still). IPE could have presented in many of the ways described especially during the dive (as could have CO2 and the bends). This stuff isn't like they come out of the water with a flashing neon sign saying what is wrong.

That all said, every tech diver should know how to conduct a rapid neuro (often called a 5 min neurological) that gives both insight for first aid and in talking with EMS/DAN getting further assistance

Rapid neuro for Divers

 

[TravelGas]

I agree, this isn't directly relevant to the situation. I was pushing back at the concept of "anyone needing oxygen needs emergency transport"

If Woody would have been my patient I would have encouraged rapid transport with an ALS intercept, but that presumes a system where ALS/BLS are available on scene and patiwnts recieve care regardless of ability to pay, which was also not the case where they were. Calling DAN for all dive related injuries is also in our county protocols, which I thinknis a nice touch.

Just to be clear, I never said all PTs getting O2 need transport. I did say.
"Yes, there are times where assessment and no transport by bus, or even at all, are appropriate."

It wasn't just that Woody needed O2, it was a totality of other factors taken into account. While I wasn't there, no doubt his GCS was also reduced, he did have LOC. I would give 500cc Lactated Ringers, if I didn't have access to that in that environment, then Normal Saline and monitor PT.
The video was lacking in information, I bet his BP was low (dehydration & LOC) and he needed his Systolic pressure brought up to at least 90. An NPA would not have been a bad idea either since he was Unstable and needed rapid transport/diesel therapy.
By contrast, calling DAN in my AO is not protocol, contacting Medical Control is.
Gus is welcome to contact DAN. If I were outside CONUS, then I would call DAN or other resource to consult. I am flying under my own flag at that point. I don't need a flashing Neo sign, my PT. assessment skills are on point, I will figure it out.