Andrew • July 22, 2008 2:23 AM

@Brandioch Conner

Your personal attacks are way out of line. My employer has my registry information. The agency I volunteer with has a copy of my certs. As you point out, anyone can say anything. This apparently includes you. Please tone it down a notch. You are making yourself look very bad and hurting your cause thereby.

If you must make matters personal, Mr. Conner, please start by stating your credentials and/or your personal experiences. If you have neither, your arrest record will serve in its place.

And what determines whether a person is a “patient” or not?

That’s a really cogent question. Most EMS agencies respond to a call for service, whether generated by a 911 call center based on a telephone call, less often by radio request from police, and once in a great while from self-dispatch (i.e. discovering a traffic accident or eating lunch when someone chokes).

So the medics are almost always there because someone called. Passers by, relatives, the manager or security or police, etc. Generally people who want to make sure that the ill or injured person gets help.

Most patients want help and will say so when asked. A stroke patient may be reduced to squeezing the medic’s hand in reply, but would you prefer that we dump them in the street because they cannot verbalize a loud “Please help me, my body doesn’t work and I can’t move or talk!”

Patient refusal of medical care is taken very seriously. A conscious adult without clear (and thereby noteworthy, as in hold up in court documentation) signs of altered mental status has the absolute right to refuse care. The medics whip out an AMA (“against medical advice”) form, ask the person to sign, and document either their signature or their refusal to sign. Then the medics clear the call and leave. This may save several thousand in ambulance bills, or cost a life. But it was not the choice of the medics, but rather the patient.

A cardinal rule of the EMS system is that except in emergencies, no one works alone. This saves lots of problems and guarantees witnesses in touchy situations, which are common enough that all EMS personnel are trained for them.

It is standard policy when a person refuses care and the medics think they need care to call for a higher level of care (i.e. paramedics) and/or the police. This is also true when a parent withholds important care from a child, as in an apparent abuse situation.

A prisoner already in police custody when medics arrive is in an awkward position. The prisoner’s ability to refuse care is much more limited. Generally, basic life saving care must be provided and if life is in danger, transport to an appropriate hospital facility is required.

Otherwise, a prisoner who refused care might die in custody. That would be bad. Flinging blood and body fluids on police is also frowned upon (and a serious crime), so someone bleeding might end up with bandages they don’t necessarily want for that reason.

Almost all medics do not work for the police (exception: some are EMT-Basics, a handful work for combined police /fire agencies, plus some state police have flight paramedics or nurses.) Medics do not gather evidence for police nor do they believe that their job is to judge their patients. If physically prevented by police from doing their jobs, they report this immediately to medical direction and document in great detail.

Not incidentally, jail facilities will refuse to take prisoners if the facility is not equipped to handle the prisoner’s apparent medical needs, including psychiatric if applicable.

All EMS system actions are documented and carefully tracked. This quality of care assessment is continuous and supervised by physicians and government officials. Misconduct can and does result in remediation and license actions.

If 4-8 cops come up to you and start violating your civil rights and you object, that is the “excited delirium” we are talking about here.

No, no, and HELL NO. Medics do not normally get involved in police activity. Doctrine is to stage nearby pending police arrival and only enter when the scene is secure. Exception: Tactical EMS which is performed by peace officers (full or part time) who happen to have medical skills, sometimes carry guns and usually accompany SWAT teams.

A handcuffed person on drugs sitting up in the back of a squad car and screaming at the cops while bleeding from a cut is so routine as to be yawnworthy. As long as they’re screaming, they’ve got an airway. As long as they’re moderately competent in their swearing, they’ve probably got a normal mental status. It is a thankless job to check. “Hi, sir, what’s your name and do you know where you are?” is as often greeted by “Go F@#% Yourself” as it is “What does it look like, I’m in the back of a pigmobile and my name is Suspect #1.” Either one is probably a normal mental status, all things considered — but the medics still go down the checklists, and sometimes find that the drunk is actually a diabetic, or the guy smashing cars with a rake is actually the victim of a prior mugging that resulted in head injury.

ED is when you get a call about a guy who is extremely violent, has torn off all his clothes, has smashed out windows he could reach, is screaming in the street, has little or no reaction when spoken to, and it’s a multiple casualty incident because there are two or three injured cops as well. He’s literally hot to the touch, feels no effect from all police weapons (including being shot!) but Taser and that only briefly, and is on a rapid road to death, whether immediate from hyperthermia or positional asphyxiation, or later in the hospital from metabolic damage and multi system failure.

There can be no mistaking an ED case for an angry suspect, or an ordinary citizen who is asserting their rights, or even an ordinary person under the influence of drugs. It’s not LSD or cocaine or meth either. It’s a life threatening medical emergency that presents as extremely violent behavior with the signs above.

Now if this person with ED was your father, what would you have the police do? Shoot him? Or call for the medics (who are independent witnesses to police behavior!) to stabilize him after control is finally gained. Or (perish the thought) ask that the medics inject him with a ‘lethal dose’ of something other than high velocity lead?

@gopi
“If something happens to the patient, the EMT-P is going to have to answer for it.” >> Yes, by filing the “cause of death” as “excited delirium”. As seems to be happening in more and more cases.

I thought the ignorance about the EMS system was appalling. Apparently knowledge of homicide investigation and the operation of the coroner’s office is also lacking here.

Paramedics have nothing to do with death investigations other than being a witness and filing accurate reports.

To assert that a paramedic would be willing to lose their license by lying is absurd. Trust me, medics do not feel that much loyalty to cops, or even to other medics.

Now you may be okay with playing executioner but that does not mean that society has to accept it.

Snarf. Are you a troll?

Paramedics bust their butts day in and day out to save the lives of people that many of us would step over in the gutter. The forgotten, the unloved, the vicious. EMTs in their own humble way try to make life easier on paramedics, but still do the majority of lifesaving in rural communities.

Yet you would support a lethal injection of Midazolam

You fail the laugh test. I’ve had it for a medical procedure and I am very much alive (pinches to check). Any medical procedure has risks, including emphatically any medication, but calling Versed ‘lethal’ is grossly ignorant.

I’ll take a shot at the ‘simple questions.’

1. What determines when your become a “patient” who can be injected with whatever the “medical personnel” WANT to inject you with?

You, assuming that you are competent to refuse care.

If you are not competent to refuse care, any doctor or a licensed member of the community EMS system, operating under protocol and thereby under a doctor’s supervision, can assert that you are a patient. They must then carefully document and account for their actions and bet their license on every action taken that the action was in YOUR interest. The civil law provides for this (Section 5150 of the Health and Safety Code in California). There are criminal and civil sanctions possible if this is abused and every medical professional knows it well.

2. How can someone be diagnosed with “Excited Delirium” during a routine exam by his/her regular doctor?

Not at all. I am indulging in the most idle speculation here, but I cannot imagine a person experiencing ED would be getting a routine exam, any more than would the victim of a car wreck or gunshot wound or heart attack or stroke. It is by nature an acute and life threatening medical emergency.

A doctor would promptly call 911 and probably flee their own office if an ED victim were to suddenly materialize inside. Their only tool would, ironically enough given where we started, be powerful muscle relaxants or tranquilizers given IM, followed by rapid recognition of heat stroke once they took effect. If the doctor didn’t have ready access to appropriate medications, we’d be back to police restraint and paramedic treatment, with many of the same risk factors as in the street.

As for ED, National Association of Medical Examiners does recognize it; AMA and AHA does not. It is not in the DSM-IV. I’ve taken training on ED and seen videos of ED episodes.

I’m not disputing that police are a major contributing factor with respect to in-custody death. I am disputing the idea that police somehow want to go out of their way to kill suspects, or are engaged in a massive conspiracy of silence to literally get away with murder in most public and brutal fashion.

Positional asphyxia can and does kill persons in custody. Training police to recognize and prevent it is vital. Any medic immediately recognizes it as an airway threat — a skill not beyond that of the intermediate first-aider, which all police are supposed to be.

Besides, as any resident of Chicago can tell you, drop guns are the accepted method for police murder.

Andrew • July 22, 2008 1:12 PM

I am just a working grunt pointing out what seems to me to be gross errors in a subject I happen to know a few things about. I’m not trained as a scientist or as a medical professional above the very basic “Load and Go” expected of any EMT, or to use the phrase we dislike, ‘ambulance driver.’ Anything I happen to get right, great. Anything I get wrong, sorry. I’m engaged in a search for truth and if I learn something I didn’t know, so much the better.

If anyone reading this wants to become an educated layperson, great. The Intarwebs are at your disposal. If you want to go further and take a First Responder (53 hour) or EMT-Basic (120 hour) training class, so much the better. This training will equip you to help save lives without requiring that you make a full time career of it.

If you don’t have that kind of time, contact your local EMS and ask to do a ride-along with the medics. If you are really concerned about ED and/or police misconduct, you might do better to request a ride-along with the police, but be aware that you might learn something about policing along the way.

I answered Conner’s question, paraphrased as “What makes a [nonconsenting] adult into a patient in the EMS system in the United States?” in great detail.

His purported answer to the “how to become a patient” question is wrong on so many counts I hardly know where to start. Let me quote him:

Someone becomes a patient when they (or a responsible family member) agree to let the medical person treat them …

A “responsible family member” cannot make such decisions over the wishes of a competent adult in the field. A durable power of attorney for health care is the only ‘field’ document that a medic can accept. “When in doubt, transport” is the rule.

or take custody of them.

Let me spell this out clearly. Involuntary civil custody requires physician and police involvement.

Or when they are physically unable to refuse treatment

Withholding verbal consent is sufficient. There is no requirement that a patient be able to fight off a medic.

Also, a patient with a DNR order and/or medallion has refused care in advance, sometimes even life-saving care, because of their personal beliefs.

The doctrine of implied consent (taught in first aid!) is that an unconscious person is presumed to need emergency medical help. A bystander is not required to help; people with a legal duty (i.e. you were in a car wreck with them) can incur civil liability by not calling for help; licensed professionals and emergency responders MUST help.

AND are suffering life-threatening (their life) physical injuries.

Your caveat (“their life”) makes no sense in this context. If someone is threatening someone else’s life, the police are well within their rules to shoot the aggressor, if lesser means fail. (Depending on local law, there may be no requirement to even attempt lesser means . . .)

You also exclude illness as a life-threatening condition, which in altered mental status cases is a more common cause than injury.

AEIOUTIPS (Alcohol, Epilepsy, Insulin, Overdose, Underdose, Trauma, Ingestion/Infection, Psychological, Stroke)

I suppose this is just me spewing out more tangents. Any medics got my back here?

In reply to Conner’s points:

1. People are dying in police custody.

True. It’s a problem. Versed isn’t killing them, and neither are the paramedics. The police and a number of in-custody death experts argue that the police aren’t killing them either. Thus the ED hypothesis. While this claim should be viewed with several grains of salt, especially because of its sources, correlation is not causation.

I believe the burden should be on the police to prove that they are not killing these people. So do many police and almost all medical examiners. Thus the term ‘ED’ as a phenomena, field protocols (which include calling the medics immediately!) and postmortem evidence collection including brain temperatures.

2. The reports are listing “excited delirium” as the cause of death.

True. This determination is being made primarily by medical examiners, whose job it is to make such determinations. Cocaine or other hard drug overdose doesn’t seem to fit, neither does heat stroke, and autopsy results are incompatible with them being beaten to death or for that matter shocked to death. Positional asphyxia is almost certainly a contributing factor in some cases, but not the primary cause of death. I’m neither qualified to nor interested in disputing M.E.s, who are career experts in causes of death.

3. The AMA does not recognize “excited delirium” as a medical condition.

So what? The AMA is just another industry association. Appeals to authority are boring at best. Show me an AMA statement condemning ED as junk science, or doctors or medical examiners stating authoritatively that it does not exist, and I’ll be far more interested.

4. Medical personnel are being called in to administer drugs to control people deemed to be suffering from “excited delirium”.

Medical personnel are being called to respond to the life-threatening emergency which we call “excited delirium” (for lack of a better term, you can call it crazy naked man running in the street if you want). The tools in their box are very limited because medics don’t carry Tasers (nor should they). They have lots of warm bodies (firefighters are good for something 🙂 ), soft restraints and Versed. That’s about it.

Are you trying to say that medics are not qualified to recognize ED? Or that police are not qualified to recognize ED? When trained police are routinely called as expert witnesses to alcohol and drug intoxication in almost every court in the country?

Once the medics show up, they administer the care that the patient requires in the medic’s best professional judgment, under the authority of their license and their medical direction. No one (in my county and I strongly suspect in any urban county in this state) is giving these drugs in the field who is not a paramedic, that’s over 800 hours of training followed by extensive internship; after being a working EMT-Basic for at least one year.

A medic ordered to inject drugs into a patient by a police officer would refuse. Many would document the request to prove that it was not honored, to cover themselves. Some would complain informally; others would make the complaint formal and at length.

5. Those drugs are being administered to the victim without any knowledge of the victim’s medical history or current condition.

Medical history, true. I challenge you to take a history on someone who is not verbally responsive and suffering from any severe drug reaction. If you happen to glimpse a Medic Alert bracelet, etc. great. If witnesses or relatives are present and will answer questions, even better. If prescription bottles are available, that’s helpful too.

Current condition, false. Medics are trained to evaluate a person’s condition using whatever tools are at hand. Re-read my description of a classic ED case above. You don’t need to slap on a BP cuff and insert a thermometer to realize that this person is in a bad, bad way and needs immediate help.

This last part is specifically for Conner.

I ask again: What are your credentials, other than as a computer wonk? (As everyone on this site should know well, expertise in one subject does not make a person an expert in other subjects.)

Again, please state your credentials, or personal experiences, or even prejudices so that we can give your opinions the proper weight they deserve. I will settle for “Google-fu” but would prefer evidence of you having read material you disagree with.

Conner, you’re right, I jumped to the conclusion that you’ve had negative contact with police. If you behaved in the street as you behave here, you’d almost certainly have an arrest record.

Please read my answers carefully. If you need words or concepts explained, I will do my best. There is a lot in this world that you do not know, just as there is a lot in this world that I do not know. Please don’t dismiss my posts as ‘stream of consciousness’ just because it is foreign to your past experience.

If you continue to believe that I am making up nonsense to confuse you, the Constitution gives you the right to believe this. I don’t have to humor you. I don’t accept correction from you either. I have a chain of command and supervisors for that.

What is your theory with respect to ED? What do you think is causing this type of well-documented death? I’m all ears.

Conner, I want to know what your agenda is, because right now I frankly don’t see anything other than police-bashing extended by proxy to medic-bashing, in all apparent ignorance of any difference.

That bothers me and I need your help to understand your point of view. Thanks.

Andrew • July 24, 2008 11:36 AM

An aside on EMT status as a security authentication issue.

I could if I chose provide proof, verifiable over the Internet, that I am in the National Registry. I could post a scan of my EMT license issued by my county, or one of two identification cards issued by other agencies.

However this would not only compromise my anonymity but open me up to identity theft. Anyone could go around claiming to be me.

The claim that I am an EMT is therefore supported by what I wrote: material which BC dismisses as ‘stream of consciousness’ but is in fact readily recognized by other EMTs and those who work in prehospital emergency medical care.

It’s very hard to ‘sling the lingo’ without at least passing familiarity with the subject. I could not convincingly emulate a network engineer, for example, by blathering about TCP/IP, stacks, Ethernet, port numbers etc. I might fool a layperson but most of the readers of this group would see right through it and I would lose all credibility.

This is a business where our words are our reputation. In a strange sort of way, the ability to discourse meaningfully on an arcane subject is itself a form of biometric security.