Re: More phone triage musings

[Guest guest]

Kenny Navarro wrote " There are outliers in everything that medicine (in general)

and EMS (in particular) does. Every EMS system has treatment protocols (or

guidelines) written for the largest area under the bell curve but it seems

unlikely that they are comprehensive enough for all possibilities. In fact, if

we could plan for the outliers, would they really be outliers? Is this really

the criterion (possibility of an outlier) that we use to determine not to do

something? "

A valid academic argument but does that above statement not lead one to argue

that due to the inherent risk where there is no data or in fact may be data that

supports the potential for harm to have us (EMS in this case) to err on the side

of caution?

Louis N. Molino, Sr. CET

FF/NREMT/FSI/EMSI

Typed by my fingers on my iPhone.

Please excuse any typos.

(Cell)

LNMolino@...

On Aug 1, 2010, at 19:58, " knavarro141 " kenneth.navarro@...>

wrote:

> Gene Gandy wrote: >>> No matter how well planned and implemented, there will

always be the " outlier call " that will fall through the cracks and the system

will fail. <<<

>

> There are outliers in everything that medicine (in general) and EMS (in

particular) does. Every EMS system has treatment protocols (or guidelines)

written for the largest area under the bell curve but it seems unlikely that

they are comprehensive enough for all possibilities. In fact, if we could plan

for the outliers, would they really be outliers? Is this really the criterion

(possibility of an outlier) that we use to determine not to do something?

>

>

>>>> Attempts to try to triage calls using nurses seem to run in cycles.

Somebody tries it, a disaster happens (remember Nurse Myrick in Dallas) and the

system is dropped. <<<

>

> How can we forget, you bring up than name every time this discussion surfaces.

Should we declare a moratorium on call triage based on an incident that happened

before many people on this list were even born? If so, do we declare a

moratorium on endotracheal intubation, helicopter transport, and analgesic

administration? Perhaps it is possible to learn from the past and create a

process that minimizes the chance of a previous mistake happening again.

>

> BTW the incident involving the nurse that you are so fond of referencing was

not a failure of the process; it was a failure of the nurse. Had she followed

the process, the family would not have waited so long for an ambulance, although

whether it would have prevented the death is a matter of speculation.

>

> One may argue that all subsequent attempts as call triage will still have the

human factor as (arguably) the weak point. But, that same weakness exists in

dispatching in general as well as in the back of the ambulance. Do we really

want to limit implementation of anything in which the human factor is involved?

>

>

>>>> The idea that nurses somehow have magical powers … <<<

>

> I've met some nurses that seemed to have some extraordinary powers that

bordered on magical, but I digress.

>

>

>>>> Can you imagine a single physician who would agree to make response

determinations over the phone? If you know one, let me know. <<<

>

> Yes, Jeff Clawson. Now you know one.

>

>

>>>> I haven't heard of any disasters coming out of that system (Houston), but a

disaster is inevitable simply because it's impossible to see what's happening on

the other end and when you're talking to medically unsophisticated people,

you're not going to get reliable information about what's really going on. <<<

>

> By those criteria, " disasters " are inevitable in any system regardless of

whether they use a call screening process.

>

>

>>>> I'm not saying that when a person calls and says " I cut my finger while

slicing tomatoes " that the Cavalry need to be dispatched. It doesn't take a

nurse to determine that. But when somebody calls and says " I've got a stomach

ache " there's no way that person's condition can be evaluated over the phone.

<<<

>

> Just so that I am clear, are you saying that it works in some cases but not in

others? That seems to be contrary to the gestalt of your post.

>

>

>>>> The " patient lift assist " call where a patient has fallen and just needs

help in getting back to bed. That call CAN be handled by a lower grade response

IF the right information is gained by the call taker and interpreted correctly.

<<<

>

> Didn't you just write that " it's IMPOSSIBLE (my emphasis) to see what's

happening on the other end and when you're talking to medically unsophisticated

people, you're not going to get reliable information about what's really going

on " ? (For those of you keeping score at home, the answer is " Yes, he did. " )

>

>

>>>> But there's lots of room for screwups there as well. <<<

>

> And with that potential, we should never try it.

>

> Gene may be right on this issue. I suspect, however, that there is an equally

good chance that he is not. There is an even better chance that systems will do

as they please regardless of any pontification by Gene (or I).

>

> Kenny Navarro

> Dallas (home of Myrick)

>

>

>

>

> ------------------------------------

>

>

[Guest guest]

As you say, systems will do as they please. The trial lawyers love them and

thank them for that.

GG

More phone triage musings

Gene Gandy wrote: >>> No matter how well planned and implemented, there will

always be the " outlier call " that will fall through the cracks and the system

will fail. <<<

There are outliers in everything that medicine (in general) and EMS (in

particular) does. Every EMS system has treatment protocols (or guidelines)

written for the largest area under the bell curve but it seems unlikely that

they are comprehensive enough for all possibilities. In fact, if we could plan

for the outliers, would they really be outliers? Is this really the criterion

(possibility of an outlier) that we use to determine not to do something?

>>> Attempts to try to triage calls using nurses seem to run in cycles. Somebody

tries it, a disaster happens (remember Nurse Myrick in Dallas) and the system is

dropped. <<<

How can we forget, you bring up than name every time this discussion surfaces.

Should we declare a moratorium on call triage based on an incident that happened

before many people on this list were even born? If so, do we declare a

moratorium on endotracheal intubation, helicopter transport, and analgesic

administration? Perhaps it is possible to learn from the past and create a

process that minimizes the chance of a previous mistake happening again.

BTW the incident involving the nurse that you are so fond of referencing was not

a failure of the process; it was a failure of the nurse. Had she followed the

process, the family would not have waited so long for an ambulance, although

whether it would have prevented the death is a matter of speculation.

One may argue that all subsequent attempts as call triage will still have the

human factor as (arguably) the weak point. But, that same weakness exists in

dispatching in general as well as in the back of the ambulance. Do we really

want to limit implementation of anything in which the human factor is involved?

>>> The idea that nurses somehow have magical powers … <<<

I've met some nurses that seemed to have some extraordinary powers that bordered

on magical, but I digress.

>>> Can you imagine a single physician who would agree to make response

determinations over the phone? If you know one, let me know. <<<

Yes, Jeff Clawson. Now you know one.

>>> I haven't heard of any disasters coming out of that system (Houston), but a

disaster is inevitable simply because it's impossible to see what's happening on

the other end and when you're talking to medically unsophisticated people,

you're not going to get reliable information about what's really going on. <<<

By those criteria, " disasters " are inevitable in any system regardless of

whether they use a call screening process.

>>> I'm not saying that when a person calls and says " I cut my finger while

slicing tomatoes " that the Cavalry need to be dispatched. It doesn't take a

nurse to determine that. But when somebody calls and says " I've got a stomach

ache " there's no way that person's condition can be evaluated over the phone.

<<<

Just so that I am clear, are you saying that it works in some cases but not in

others? That seems to be contrary to the gestalt of your post.

>>> The " patient lift assist " call where a patient has fallen and just needs

help in getting back to bed. That call CAN be handled by a lower grade response

IF the right information is gained by the call taker and interpreted correctly.

<<<

Didn't you just write that " it's IMPOSSIBLE (my emphasis) to see what's

happening on the other end and when you're talking to medically unsophisticated

people, you're not going to get reliable information about what's really going

on " ? (For those of you keeping score at home, the answer is " Yes, he did. " )

>>> But there's lots of room for screwups there as well. <<<

And with that potential, we should never try it.

Gene may be right on this issue. I suspect, however, that there is an equally

good chance that he is not. There is an even better chance that systems will do

as they please regardless of any pontification by Gene (or I).

Kenny Navarro

Dallas (home of Myrick)

[Guest guest]

Gene:

In any of these these scenarios information is the key, trained dispatchers are

the key link in the chain. I have had this problem,where I get as little or no

information from my dispathcers  as well, as non being assertive enough to get

it. The key factor here is training

which no one is willing to provide or budget the money for. We also face the

cultural problem of understating the problem and that is solved with

assertiveness.Also,asking the right questions. I have gone into many call blind.

Also, have the right number of personnel on scene is important. PD,FD, and EMS.

As the situation unfolds, as situation can be collapsed, and a tapout or excess

people can be returned to service. We also have to serve other medical needs

such as lock outs, and sometimes charging an exorbitant fee for mistakes does

not serve the purpose for bailing our citizens out of a bad situation,or pouring

salt in to an open wound or upsetting situation. I moved to Laguna Park,Tx with

my fiancee Candace and I will be riding into the sunset,with cavalry stetson.

Take Care,Rabbiems.Doc.

>>> No matter how well planned and implemented, there will

always be the " outlier call " that will fall through the cracks and the system

will fail. <<<

There are outliers in everything that medicine (in general) and EMS (in

particular) does. Every EMS system has treatment protocols (or guidelines)

written for the largest area under the bell curve but it seems unlikely that

they are comprehensive enough for all possibilities. In fact, if we could plan

for the outliers, would they really be outliers? Is this really the criterion

(possibility of an outlier) that we use to determine not to do something?

>>> Attempts to try to triage calls using nurses seem to run in cycles. Somebody

tries it, a disaster happens (remember Nurse Myrick in Dallas) and the system is

dropped. <<<

How can we forget, you bring up than name every time this discussion surfaces.

Should we declare a moratorium on call triage based on an incident that happened

before many people on this list were even born? If so, do we declare a

moratorium on endotracheal intubation, helicopter transport, and analgesic

administration? Perhaps it is possible to learn from the past and create a

process that minimizes the chance of a previous mistake happening again.

BTW the incident involving the nurse that you are so fond of referencing was not

a failure of the process; it was a failure of the nurse. Had she followed the

process, the family would not have waited so long for an ambulance, although

whether it would have prevented the death is a matter of speculation.

One may argue that all subsequent attempts as call triage will still have the

human factor as (arguably) the weak point. But, that same weakness exists in

dispatching in general as well as in the back of the ambulance. Do we really

want to limit implementation of anything in which the human factor is involved?

>>> The idea that nurses somehow have magical powers … <<<

I've met some nurses that seemed to have some extraordinary powers that bordered

on magical, but I digress.

>>> Can you imagine a single physician who would agree to make response

determinations over the phone? If you know one, let me know. <<<

Yes, Jeff Clawson. Now you know one.

>>> I haven't heard of any disasters coming out of that system (Houston), but a

disaster is inevitable simply because it's impossible to see what's happening on

the other end and when you're talking to medically unsophisticated people,

you're not going to get reliable information about what's really going on. <<<

By those criteria, " disasters " are inevitable in any system regardless of

whether they use a call screening process.

>>> I'm not saying that when a person calls and says " I cut my finger while

slicing tomatoes " that the Cavalry need to be dispatched. It doesn't take a

nurse to determine that. But when somebody calls and says " I've got a stomach

ache " there's no way that person's condition can be evaluated over the phone.

<<<

Just so that I am clear, are you saying that it works in some cases but not in

others? That seems to be contrary to the gestalt of your post.

>>> The " patient lift assist " call where a patient has fallen and just needs

help in getting back to bed. That call CAN be handled by a lower grade response

IF the right information is gained by the call taker and interpreted correctly.

<<<

Didn't you just write that " it's IMPOSSIBLE (my emphasis) to see what's

happening on the other end and when you're talking to medically unsophisticated

people, you're not going to get reliable information about what's really going

on " ? (For those of you keeping score at home, the answer is " Yes, he did. " )

>>> But there's lots of room for screwups there as well. <<<

And with that potential, we should never try it.

Gene may be right on this issue. I suspect, however, that there is an equally

good chance that he is not. There is an even better chance that systems will do

as they please regardless of any pontification by Gene (or I).

Kenny Navarro

Dallas (home of Myrick)