Riblett

Hello EMS friends, I will be traveling to the UK and Ireland in June 2019 (next month!) and I am hoping to learn more about the EMS systems in England, Wales, Scottland, and Ireland first hand. The process of cold contacting all these agencies seems overwhelming (although I will if needed). My excitement was dashed a bit when I read on their website that London Ambulance Service does not do ride alongs. But they will allow other healthcare providers to visit with the proper paperwork. To my colleagues across the pond: Can you give me any insight into how to approach this? Do you know of any 911 agencies that would allow an international ride along? Where should I start? A bit about me. I am a paramedic of over ten years and an EMS instructor. I am also a nurse practitioner specializing in emergency medicine and a former ER nurse. I can provide all manner of background checks and letters of introduction/recommendation from my employers and faculty. Is this realistic? Can it be done? Thank you in advance.

Thanks for the insight, Mike. To answer your question, the severe electrolyte deficiencies resulting in hospitalization has me very concerned.

Conflicted in this scenario so I am putting out for the masses to advise. I'll keep it fairly to the point. Scenario: You have a new EMT join your volunteer squad who is a non-insulin dependent diabetic. They take oral hypoglycemic agents. This EMT has experienced multiple incidents involving low blood sugar while on duty or otherwise present at the station. Incidents have been varied in severity, but all resulting in inability to function in a patient care role. This EMT is considerably overweight and is openly engaging in crash dieting and you think the two are obviously connected. They have also been treated at the ER for fluid/electrolyte issues. They have been mandated by the chief to check their blood sugar every two hours while on duty; seems compliant. Also been mandated to consume a meal BEFORE reporting for duty, since they may have a call right at shift change and be unable to eat. They habitually fail to eat prior to reporting for duty and seem very hesitant to eat unless they start to feel sick. As a squad officer, what do you do? 1. At what point do you suspend them from duty? Is there any possibility that doing so could be considered discriminatory? 2. What conditions would you put in place if you were to allow them to return? (written contract, perpetual third rider status, MD letter, etc) 3. At what point do you consider contacting family/parents, etc due to suspected life threatening eating disorder? Age 19. You also have some suspicions of histrionic/Munchausen type behaviors.

Hi Folks, Trying to help my little sister in law transition from North Carolina to Wisconsin. I am a paramedic here in NC and she is a cadet who has passed her EMT-Basic class and test; still waiting for the 18th birthday in a few weeks for her certification to be issued. Yes, I corrupted her with the dark world of EMS Unfortunately, my experience and contacts have fallen short of being any assistance in this move so far. Anyway, she is moving with the parents to Wisconsin at the end of August. They are moving to the Oshkosh area and living in the Neenah area. She is going to UW at Oshkosh in the fall, undecided with college major for now. She really wants to volunteer and eventually work as an EMT in WI. She would like to consider Paramedic or Intermediate education there as well, but we are not sure where to start. Being from NC and 17 she has no fire background and no experience besides cadet. Does anyone here know how the EMS systems there are structured and what her options might be? How is EMS education structured there? Any tips or advice you can offer one of our profession's young in this unknown land ? Thanks a bunch for any insight you have.

So I have not been on EMT City for a while now, but I guess I might find some like minds or at least some folks with similar experiences here. A little background, I am currently a paramedic and an EMS instructor. I have been in EMS for eight years, five at the paramedic level, two as an Intermediate, and one as a Basic. I have an AAS in EMS and a BS in Health Science with a concentration in health care provider education. After several years of prerequisites and applications, this past year I finally got into nursing school with the hopes of being a nurse practitioner. Yay for me...or so I thought. Accelerated BSN program was where I ended up. I am currently in my second semester out of five and frankly I WANT OUT! I am so incredibly frustrated with the whole experience. My grades are good enough, usually top 25% of my class for nearly everything, but they are driving me crazy. These nursing instructors defy the laws of physics by simply getting their heads through the classroom doors in the morning. They are rude, condescending, unorganized, and frankly treat the students like something they scraped off the bottom of their shoe. They make the cockiest brattiest new medic seem as humble and gracious as a saint. They seem to pride themselves on being so incredibly esoteric and complicating even the simplest of information to the point of exasperation And to make it worse, they don't even seem to have the knowledge to back it up. They make blatant and irreconcilable errors in the information they present. Examples: A-fib is a shock-able rhythm. Narcotic antagonists are a class of pain medicines. Hemorrhoids are weak muscles. Give aspirin to stroke patients. These are just some examples I have recalled in the last thirty seconds. And if I pick up on these I wonder how many more there are that I simply don't know any better than what they are saying. I should say that I have actually had two awesome professors, who exceeded my expectations in their teaching abilities and clinical knowledge. But the rest of the instructors, I can't even describe. Their lectures are God awful. It seems that none of what I study is on the exams. I have tried the textbook, the lectures, study groups and everything. But the tests come around and it seems like the test was taken from another class or another school. And when everyone fails, the instructor are oblivious to the fact that they might need to do something a little different. There also seems to be complete and total lack of consistency in practical skills evaluations. Clinical skills evaluations are something I have done as an instructor for many years, and I find it very disturbing to see one student pass a station and the next student failed for doing the exact same thing. The entire profession seems to have chip on their shoulder bigger than the US deficit. They are more concerned about teaching students nursing theory and how nurses are "professionals in their own right." etc. I wish they spent half as much time and effort actually teaching factual information and skills. And "nursing diagnosis" OMG. A collection of esoteric BS which does nothing other than satisfy some inferiority complex nurses have against the MDs. Google it if you haven't ever heard of it. I would NEVER treat any of my students the way we are treated. We are talked down to, screamed at, made to feel stupid in front of patients, family members, and class mates. And to make the process way more degrading, we have to wear see through white scrubs. That is right, see through clothes. And an apron. ​ And being on a geriatric floor in that outfit means basically having a sign on your back that says "free adult diaper changes." I have spent so much time and money to get here, but frankly I am so stressed I don't know if it is worth it. I dread getting out of bed in the mornings. Anyone else take the RN path? How did it go? How did you cope with any issues you had? Am I just at a bad school? What should I do differently? On the first day of class we had to go around the room and tell our names, backgrounds, and previous education. After myself and the military corpsman did ours, the instructor went on a ten minute rampage about how inferior medics are and how they shouldn't be allowed to do anything other than take people to the hospital, etc. (My paramedic education was six semesters, full time, no cook book medicine. I don't get frustrated with having to learn theory. In fact, I value an appropriate amount of theoretical education. All my EMT Basic students walk into their state exam able to describe in their own words the pathophysiology behind every major emergency condition we see, the ins and outs of every drug they give, and how and why to do every skill in their scope, but I digress )

I am back guys, got stuck at a station with no wifi for 24 hours (deplorable, I know!) So most of my students are under 25 years old, mostly young volunteer firefighters. Maturity level has certainly not been the highest with this group, but I do have some very good ones. After the behavior seemed to make a female student I was using as a patient uncomfortable I changed it to where I was acting as the patient. I made them conduct the physical assessment on me. Which, on a side note, is a whole different outlook on grading your student performance. I think I may put myself in the patient role more often and have a student or assistant instructor calling the scenario. It was a double edged sword in that it stopped all giggling and immature behavior, but it made the ones who were uncomfortable touching female 'patients' even more nervous. Taking your advice I cracked down and reset the tone of their scenarios. During end of chapter skills check off I told them point blank that if they laughed or did anything inappropriate their scenario stops, they receive an automatic fail, and will have to remediate outside normal class hours. I was the patient and had an assistant instructor calling the scenario. We evaluated them as a team.

I am having some difficulty getting my EMT students to conduct assessments appropriately, particularly on opposite gender 'patients.' The female students don't seem to have an issue with it. Some of the male students don't take it seriously and laugh the whole time. Others are so uncomfortable that the stammer through the whole thing and don't do an accurate assessment because they are too scared to actually touch their classmate. I am not talking about ob/gyn type stuff here, just your typical secondary survey (head to toe) on a fully clothed fellow student. Obviously this involves assessing the chest area to assess the clavicles, ribs, and sternum, but I (a female instructor) am always present when they are doing opposite gender practice assessments. I try to make sure they can practice assessing patients of both genders, but now I am reconsidering. Should we not be making our students peform assessments on opposite gender during their class? Should we allow them to opt out? How will this effect their ability to perform them in the field?

Crochity, I am not saying that payment was an issue in this case. I was saying that your description of the ER was not accurate. They are more than capable of treating pediatric patients, and do so quite often. What they lack is the ability to admit those requiring ICU care. I think that this case has everything to do with EMTALA. Its sole purpose is to ensure equal care for all and prevent hospitals from transferring patients inappropriately. If we routinely circumvent it by transferring patients from the waiting room that have not been screened, stabilized, and certified for transport we open ourselves up to huge liability. If we take part in these transfers, what is to stop them from being performed in the future based on a persons ability to pay, etc? As I said, if the hospitals know we'll bypass the laws and just transfer them then why not just leave the ones they don't want to treat in the waiting room?

Crochity, I am the OP. And that was not the case.

And does you opinion change based on the level of your emergency? I mean, toe pain versus crushing chest pain for example.

This hospital typically does not admit peds, but if the child was truly unstable we would have taken them to that hospital to be stabilized anyway. It is the only hospital in our county and sees plenty of pediatric walk-ins. All other hospitals, those with specializations or admissions area minimum of 45 minutes away. It seems almost counterintuitive, because if it was enough of an emergency to need an emergency ambulance then it was enough of an emergency for them to need stabilization. If it wasn't enough of an emergency to really need the ambulance, then sit down and wait your turn. I respectfully disagree with the assessment of an emergency is an emergency no matter where it is. That is why they are in an EMERGENCY department. As much as we try to think of ourselves as high level care givers we need to realize that our ultimate goal is transportation to definitive care, which may include stabilization at an intermediary facility. If the patient is in the ER already then EMS should not be responding. Quality of care at the hospital, ED and ward, is beyond our level of responsibility. If we allow this sort of thing to take place, then what is to stop anyone is a minor ailment from getting annoyed with waiting too long and calling 911 from the waiting room? ER's do triage for a reason. Also, EMTALA is in place for a reason. If we start transferring patients out of the waiting room, not only to do we open ourselves up to liability, but provide an avenue to EMTALA to be circumvented by hospitals. A patient doesn't have insurance? Well if we leave them in the waiting room long enough they'll call 911 and get taken to another hospital. Skip evaluating them, skip stabilization, and skip facility acceptance or transfer paperwork! Just my $.02.

And before someone takes away my special points, I am aware of previous discussions of the topic from 2007.

A few nights ago, one of our County units was dispatched to the waiting room of the local community hospital. I was at another station, so I don't have a lot of details. Apparently someone called 911 from the waiting room and it came through EMD as "breathing problems." The patient was a two month old male according to dispatch. This community hospital is does not really do high acuity pediatrics, cath lab, OB, etc. But they do stabilize and transfer. This was not a transfer orchestrated by ED staff, those are paged out differently and usually go through a contracted agency. This person apparently called from the waiting room and demanded they and their baby be taken to a hospital in a neighboring county approximately 45 minutes away. The kid must not have been in that bad of shape because they crew marked en route to the other hospital "routine traffic." I don't really understand why dispatch sent an ambulance to begin with without contacting the charge nurse or something. They were already in the ER. If an emergency transfer was needed, the staff would have called for it. Should the crew have even transported this patient? It seem to me that unless they patient's guardian signed out AMA this would be an EMTALA violation and open the EMS crew up to liability. But even if they did, suppose the kid really was in bad shape or became that way and died en route to the other hospital? We have rules in place to keep unstable patients from being shifted between hospitals for just this reason. And to be sure if this child had suffered a negative outcome the lawyers would be coming after that EMS crew for negligence.

I am pretty sure it was the amniotic sac. I have seen the placenta a couple times before and it didn't look like that. This girl was visiting her boyfriend at college and lives in another part of the state. So she had no relationship with any OB in the area. There was no doc in the ward when we got there. They paged the on-call OB when we brought her in. The nurses were really not helpful. I still don't know the outcome. The only thing I was sure of on this call was that my partner was experiencing an acute Zofran deficiency

Last shift I had an OB case which I had never seen before. I was dispatched to "pregnancy problems" at the local college. The patient was on the third floor of the men's dorm building, which in accordance with Murphy's Laws of EMS had super narrow stairs and no elevator. I found a 16 year old girl kneeling on the floor of a dorm room. She had her hands over her vagina attempting to keep something from coming out. It looked like large portion of an intact amniotic sac. Before my EMT even made it into the room I called for back up. She said that she was 22 weeks pregnant and had just had sex with her boyfriend when this started. She denied any cramping or urge to push. There was a moderate amount of blood in the toilet but no fetus according to my partner whom I sent on an unfortunate fishing expedition. All I could see at the vagina was (for lack of more sensitive or appropriate term) what looked like a big bubble protruding about 3 inches. There was also what appeared to be bloody semen. I could not see any identifiable fetal parts, just the amniotic membranes. While waiting for the other crew to help us get her out of the building I took vitals and started a line. I soaked an ABD pad in sterile water and covered the vagina and membranes with it, not having any idea what else to do. We took her down the stairs in the stair chair. En route to the OB hospital I started a second line, did an basic EKG, and repeated vitals. Her vitals were normal, rather good actually. We made it to the hospital without a fetus being expelled in what must have been the longest 17 miles of my career so far. More of the amniotic sac was visible when we got to the ED but still no visible fetal parts or significant bleeding . They of course told us to proceed immediately to Labor and Delivery during call-in. (As an aside, the L&D nurse had the nerve to demand why didn't I stop downstairs to register her. Yeah, I'm going to drive emergently to the hospital, then stop off in a crowded ER waiting room with my bloody sheets, IV poles, and a half naked teen trying to deliver a 22 week fetus. Might as well let her have a look round the gift shop while I am down there, huh?) I learned nothing about this sort of situation in my education as a paramedic. I can't find much online and there is nothing in my textbooks about it. Has anyone seen this before? How would you treat this patient? What should we as field providers do in this situation?

You are right Crochity, it does not spell out the extent of the screening. Triage by an RN generally serves this purpose. What I don't understand is why we continue to treat ear infections, dental abscesses, etc, in the ER when it is clearly not mandated. Especially for patients who cannot or will not be paying for these services there needs to be a stopping point. When the ER is so full that those actually needing services are suffering medically unacceptable wait times we need to start telling people that we are not treating their minor complaints and they need to seek primary care service elsewhere. EMTALA mandates a screening and stabilization of emergent conditions without regard to ability to pay. I have studied the original law and all the updates rather extensively; no where does it mandate treatment of non-emergency issues without regard to ability to pay.

I wrote this for school, but I think it is an interesting topic for field providers. Feedback and discussion are encouraged The Role of Emergency Medical Services in the Emergency Medical Treatment & Active Labor Act: Innocent Bystanders or Culpable Party? By Candice Ryan, EMT-P, AS February 22, 2011 Nova Southeastern University BHS 3160: Health Policy Abstract The Emergency Medical Treatment & Active Labor Act (EMTALA) governs patient access to emergency medical care with respect to the hospital and emergency departments. At the most basic level it guarantees all patients who present for emergency care the right to proper screening and stabilization and governs patient transfers to other facilities. While the specific role of Emergency Medical Services (EMS) is not directly addressed by EMTALA, it does govern EMS and hospital interactions and regulates the actions of hospital in those instances. This paper will discuss four key EMTALA related issues which involve EMS providers, including hospital diversion, inter-facility transfers, ‘parking’ of patients with EMS crews within the emergency department, and ambiguity surrounding when a patient formally presents for emergency care with respect to ambulance transport. The Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986 and was designed to prevent disparities in emergency care for those lacking the ability to pay for care. It is a federal regulation applying only to hospitals participating in the Medicare or Medicaid program. Only a small number of private specialty hospitals do not participate in these programs, such as Saint Jude’s Children’s Hospital and Shiners’ Hospitals (Wolfberg, 2006). Under EMTALA, all patients who present to hospital for care have the right to a medical screening exam by qualified personnel to determine if an emergency medical condition exists without regard for ability to pay. The law does not specify the level of training which the person conducting the screening must have, leaving hospital policy to make this determination. If it is determined that a medical emergency does exist, the patient is entitled to treatment to stabilize their condition and the condition of an unborn child, also without regard to ability to pay. EMTALA also imposes heavy regulations on the transfer of patients to other hospitals (Scully, 2003). In considering the role and responsibility of Emergency Medical Services (EMS) under EMTALA, we find that both the original 1986 laws and subsequent revisions give EMS no implicit responsibility. It does make very specific provisions for interactions between EMS providers and hospitals, but it mandates the actions of the hospitals and emergency departments, rather than EMS providers. In order to be patient advocates, EMS providers need to be aware of EMTALA issues as they affect us and our patients. There is the potential for legal liability if we are party to an inappropriate transfer or illegal diversion, particularly if it results in patient injury or death. EMTALA specifies that any patient presenting to a hospital emergency room (ER) is subject to regulation. The original law was vague in terms of what actually constitutes presentation for care, making no specific provision for patients transported to the (ER) by ambulance. According to a regulations revision in 1994 by the Centers for Medicare and Medicaid Services (CMS), a person in an ambulance owned by the hospital is considered to have presented to the hospital for care even if the ambulance is not located on hospital property. A person in a non-hospital owned ambulance is not considered to have presented to the hospital, even if radio, telephone, or telemetry contact has been established (Scully, 2003). Hospital owned ambulances operating in the community response capacity are subject to additional guidelines, such as local EMS protocols. These local guidelines may mandate that patients be taken to the closest facility or hospital that is able to deliver specialized care in cases of a particular patient condition. If a patient is brought to the ER by that hospital’s ambulance service, they would be considered to have “presented for care” and as such are subject to EMTALA requirements for medical screenings, stabilization, and transfer regulations in order to be taken to a different hospital. In an updated ruling by CMS, a person in a hospital owned ambulance is not considered to have presented to the hospital if that ambulance is “operating in a community response capacity and functioning under community-wide protocols which dictate hospital destination” (Scully, 2003). In this case, the person is considered to present for care when the ambulance arrives on hospital property in the same way a non-hospital owned unit would. This ruling also extends to air ambulances and medical helicopters owned by hospitals (Scully, 2003). There is an important exception to the rule of air ambulances. If the hospital is being used solely as a meeting point for ground transport and air transport, use of the hospital helipad does not constitute the patient presenting for care despite being present on hospital property (Wolfberg, 2006). EMS may proceed in turning over care directly to air transport, without being subject to EMTALA regulations for inter-facility transfer. Another important issue known as patient “parking” is responsible for a great deal of conflict between EMS providers and ER staff, so much so that it has been the subject of several recent memos published by CMS and a target of legislation in the state of Nevada. CMS stated that they have received multiple disturbing reports of hospitals “routinely preventing EMS staff from transferring patients from their ambulance stretchers onto a hospital bed or gurney. Reports include patients being left on an EMS stretcher (with EMS staff in attendance) for extended periods of time” (Hamilton, 2006). The problem seems to stem from hospital staff mistakenly believing that EMTALA regulations are not in effect until they formally assume care of the patient from the EMS crew. Not only does this compromise patient care, but the community also has to pay for the continued patient care by EMS. EMS workers are also at risk of being liable if they don’t assert their patient’s rights under EMTALA and the patient suffers a bad outcome (Wolfberg, 2006). One particularly disturbing example is report of EMS crews waiting six to eight hours for ER staff to assume care of patients in Las Vegas area hospitals (Ludwig, 2006). To address this issue, the CMS published several memos in 2006 and 2007 asserting that “the EMTALA responsibility of a hospital with a dedicated ED begins when the individual arrives on hospital property (ambulance arrival) and not when the hospital ‘accepts’ the individual from the gurney. An individual is considered to have ‘presented’ to a hospital when he/she arrives at the hospitals dedicated ED or on hospital property” (Hamilton, 2007). The CMS further condemns the hospitals actions, stating that they raise “serious concerns for patient care and the provision of emergency services within the community” (Ludwig, 2006). As if there weren’t enough concerns around EMS and EMTALA, another topic subject to much debate in the medical community is that of hospital diversion. When hospital emergency departments make the determination that they lack the resources and capacity to accept any additional patients, they divert ambulances to other hospitals. It is important to note that this procedure does not relieve them of caring for patients who present to the hospital. Even if EMS providers disregard diversion orders, the hospital must still accept the patient as this constitutes presenting for care (Ludwig, 2006). Ambulance crews are faced with difficult choices when diversion status interferes with hospital destination protocols. EMS systems suffer decreases in efficiency as they are forced to transport patients to further hospitals and system status can be adversely affected if areas are left underserved due a lack of available units. They can even face potential liability involving hospital diversions, such as in the case of Arrington v. Wong. In this case, an ambulance carrying a patient in severe respiratory distress was diverted to a further hospital by a medical control physician and the patient died en route. The EMS crew was implicated in the negligence lawsuit in addition to the hospital and medical control physician, although the case was not actually taken to trial (Kuehl, 2002). Lastly, community based EMS providers and private medical transport providers must be aware of the EMTALA rules and regulations surrounding transfer of patients from the ER to another hospital. EMTALA regulations require a specific form to be filled out and signed by the transferring physician. Before the transfer can take place, the receiving hospital must be aware of the proposed transfer and another physician at the receiving hospital must formally accept care of the patient. The patient must be stabilized prior to transport and the risks of the transport must not outweigh the benefits. On the EMS side, only appropriately qualified personnel can conduct the transport, meaning that the ambulance must be equipped and staffed at a level that can reasonably meet the necessary standard of care (Scully, 2003). Basic life support ambulance units are obviously not appropriate for patients requiring advanced interventions or monitoring and such transports would be in violation of EMTALA regulations. Additionally, according to a 2007 memo by CMS a receiving hospital cannot condition their acceptance of an EMTALA regulated transfer based on the utilization of a specified transport service (Hamilton, 2007). For example, a receiving hospital cannot mandate that patients being transferred to their facility must use the receiving hospital’s own helicopter or ground transport service. As briefly demonstrated in this discussion, the Emergency Medical Treatment & Active Labor Act has a massive impact on EMS systems and practitioners. Many of the EMTALA-related issues between EMS and hospitals are addressed in the regulations, but ignorance of both the hospital practitioners and EMS practitioners can create situations that are at best in a gray-area or at worst are in direction violation of EMTALA and put patient care at risk. From the perspective of an EMS practitioner, the best course of action is to be explicitly knowledgeable of EMTALA and always be your patient’s strongest advocate. The Centers for Medicare and Medicaid Services are also helping to address the more difficult issues, like patient parking, with their own explicit guidance and interpretation. References Hamilton, T.E. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2006). EMTALA-"parking" of EMS patients in hospitals (S&C-06-21) Hamilton, T.E. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2007). EMTALA issues related to emergency transport services (S&C-07-20) Kuehl, A.E. (2002). Prehospital systems and medical oversight. Dubuque, IA : Kendall Hunt Publishing. Ludwig, G. (2006). CMS opinion frees up ambulances. Journal of Emergency Medical Services, 31(4), 22. Scully, T. A. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2003). Clarifying polices related to the responsibility of Medicare-participating hospitals in treating individuals with emergency medical conditions (CMS-1063-F) Wolfberg, D.M. (2006). Ems caught in the crossfire: EMTALA and ER diversions. Texas Department of State Health Services, Retrieved from http://www.dshs.state.tx.us/emstraumasystems/Wolfberg_CaughtCrossfire.pdf

There truly are too many unnecessary ambulance transports nowadays. And yes, ambulance service is expensive. Heck, I just now finished paying for my own code three ride to West Boca Medical Center from two months ago. Next time I'll ask will they give me a discount if I do my own 12-lead and IV. Joking aside, medical necessity and costs are not our concerns as providers. Unless there is truly a concern with unit availability, it should be 'you call we haul'. Even then it is an issue for the higher ups to deal with. It simply isn't worth risking your livelihood, and you don't sound like you even have a solid protocol to CYA. Personally I want to just transport anybody over 65 or under 5, no matter what the complaint is. Obviously they thought it was enough of an issue to call you. Particularly as an EMT you don't have the ability to perform even a decent differential diagnosis in the field. Those suspected kidney stones could be dissecting aortic aneurysm. That granny with low back pain could be having a big fat MI. I'll spare you the hundreds of what if's, but you get the idea.

Yikes! Biochem sucks. Here is my quick and dirty summation of biochemistry as it relates to temperature and EMS pharmacology ....the bodily activities are designed to be carried out at normal body temperature. That is the condition in which all the body chemicals (enzymes, substrates, binding agents, etc) work most efficiently. When that is thrown out of whack, enzymes may be deactivated, carriers on the surfaces of the cells may not function properly, cellular channels may not open/close normally, ion movement may be inhibited, and receptors/receptor sites may change shape to where things don't fit together as nicely as before. Metabolism, thermo-regulation, and cardiac conduction rely heavily on these types of processes. That being said, most of the pharmacological agents designed to effect these processes in the body may not work properly in extreme hypo or hyperthermia. I would not condone arbitrarily giving D50 to help with thermo-regulation because you are loading them up with a viscous and necrotizing substance. But if the patient's blood sugar is low, I would say give them the D-50. With their metabolic processes already hindered, don't make them cope with another set back of an unacceptably low glucose level.

I have just reached my two year mark as a medic, with three years at EMT-B and EMT-I level. I can tell you that the old cliche is true, it does get better with time. But to get there, you WILL have your freak out moments, you WILL spin, and you WILL have those calls where (in the words of Kelly Grayson) they wouldn't be be able to shove a knitting needle up your ass with a sledgehammer. Your first calls of every type will be scary, but when you see the same situation again it will become second nature. There is absolutely nothing wrong with keeping your protocol book in your pocket. In fact, I think all good medics will do that even many years on to their careers. And as a newbie, I lived by my ALS field guide. It was ironic because as a paramedic student I always felt sure of myself, because the final decision alway rested with someone else. As soon as I got that paramedic card, I began second guessing even my EMT/EMT-I level treatments. When all else fails, BLS before you ALS remember that it's not YOUR emergency. Air goes in and out, blood goes round and round, any variation of these things is bad. Focus on fixing the problem and don't be tempted to overthink. And just so you know, everyone still gets scared on pediatric calls, no matter how long they have been on the job. Anyone who tells you otherwise isn't being honest with you.

Laugh away, but drive by the local fast food joint and see how many ambulances, fire trucks, and police cars you see there. Then wonder why so many of us die from heart disease. Commericials have a nasty habit of providing a social mirror, don't they?

I have given intranasal Narcan several times with good effect, which beats the hell out of trying to get a vein on a junkie. And while I have my reservations about endotracheal administration of any drug, it would seem that since Narcan can be given ET and IN, it can be given as a neb. HOWEVER, why would you want to give nebulized Narcan? The purpose of Narcan is to reverse respiratory depression or apnea resulting from narcotic overdose. Unless the person's breathing is depressed or apneic, Narcan isn't indicated. And patients who fall into that category wouldn't be appropriate or effective to administer any drug via neb anyway. Unless you just want to get the crap beaten out of you don't go giving Narcan to someone just to wake them up. It's not candy and it's not a benign drug contrary to widespread belief; it can cause withdrawal seizures and delirium for chronic addicts. And even those 80 year-old grannies can swing a cane pretty hard when the come to, especially if they have been on pain meds for a couple decades. With the ability to give IM, IN, and IV, I don't really see any clinical indication for nebulized Narcan.

I think you handled this patient very well. Although I probably would have considered an anti-emetic, I can understand your line of thinking with not wanting to stop his body from throwing up a potential poison. But considering you did not have a strong suspicion of an oral medication or illicit drug OD, his continual vomiting is likely due to being really intoxicated. Besides if the ER doctor decides that his stomach contents really do need to be evacuated, an NG tube will do the job regardless. His continuous vomiting is a threat to his airway, and remember that is your priority. Break out the suction and do the best you can. Roll him on his side and keep his airway clear. Remember that as a newer generation paramedic you should not be relying on intubation as much as in the past. Expect some differences in opinion with the old-school folk. There is much less emphasis on field intubations, because in so many cases the benefits fail to outweigh the risk. Less than 8, intubate is a thing of the past. If you can manage an airway without a tube, do it. If this guy is a simple drunk, control his airway and let him sober up in the ER. He'll go home in a few hours. But if you tube him, you are potentially buying him several days in the hospital maybe even the ICU. He will require sedation (which brings in a whole new set of risks.)He may have problems surrounding extubation and be exposed to dangerous hospital acquired infections, including a potentially fatal ventilator acquired pneumonia. I am not saying not to intubate, because sometimes it is necessary. But remember that it is one of many tools in airway management and every tool has an appropriate usage.

I really intended to stay out of this one, and it looks like a consensus has already been reached. But after reading all the replies, I think this issue is A. being blown way out of proportion (MATEO !) and B. Being made way too complicated. Take it from a 20-something year old female, the population I believe that you are most likely to encounter with ob/gyn emergencies and the least likely to be educated about what exactly is going on. Pelvic/vaginal examinations, be they visualization or palpation, should be done a very strictly need-to-know basis. It will not and should not change our treatment, and spare me the 12 lead argument. There is just too much risk in this highly litigious society, especially for male providers, without any real proximate benefit. All we really need to be assessing for down there is excessive bleeding or presentation of a baby's head. If your patient is pregnant, a lot of that modesty is probably out the window anyway and a visual check for crowning is acceptable but should be done discreetly. If there is excessive bleeding you are probably going to see it. And even if you don't, you can ask in a way that even the stupidest chromosomal deficient piece of trailer trash can understand. A simple, how many times in the last 30 minutes have you had to change your pad or tampon question should give you an understanding of what you are dealing with. Some are claiming that we can't take the patient's word for how much they are bleeding and it may not be apparent, (ie we can't treat what we can't see). Well I say that any half-ass decent paramedic should be very closely monitoring any patient with vaginal bleeding, regardless of how much they claim it is or even what they see. Like Spenac said, they could be compensating with normal vitals. We should be prepared to aggressively treat hemorrhagic shock in these patients and checking out their crotch isn't going to be able make us any better prepared to do that than we already should be.