Fox800

Do you stash a bag with personal items on the truck? What do you keep in it? What kind o' bag is it?

Ex. Food, toiletries, batteries for things, interesting EMS supplies that your service doesn't stock so you acquired over the years, etc etc.

My protective gear bag has all of my issued PPE items + a spare uniform + other doodads. That's bunker gear, a winter/rain jacket, helmet, work gloves, ballistic vest, spare station boots, spare shirt/pants/belt/undergarments, and a small toiletry bag with deodorant, contact lens fluid, toothbrush/toothpaste, Tylenol, Pepto Bismol, Tums, etc.

At my gig we decide where the patient goes as well (ER vs. triage) but that isn't anywhere near the level of autonomy that the Alberta paramedics have in this case.

My current service last service have gone "all Fentanyl" when it comes to pain management, no more Morphine. My last gig did carry Nitronox. Throw that on and add some Fentanyl and you have one happy pt. Diazepam for muscle spasms, midazolam for severe anxiety.

We are expected to be at the patient's side in the vehicle, providing ALS assessment/care as needed. The fire department will also have an "inside firefighter" who's job is to support you while you are both in the car with the patient. We are issued wildland turnouts (wish they were structural gear), helmets, goggles, work gloves, and firefighting boots. At the scene of an entrapment, we are expected to be in the vehicle with the patient assuming that the scene is safe enough to permit this. As far as high angle/low angle/conspace/water rescue goes, we have specially trained Rescue Paramedics who carry rope rescue and water rescue equipment on their units. They will run the show as far as getting to the patient, stabilizing them, and working with the FDs to extricate the pt. Basically, our service has the capabilities to deliver ALS care to the patient in virtually any rescue environment (including HAZMAT).

Now that I think about it, it's true that most of EMS in Texas is provided by third services (government agencies, public utility models, or private companies). Most of the major cities have EMS run by the fire department (Dallas, Houston, San Antonio, El Paso). Austin is the only major city I can think of that has true third-service EMS as a government agency. Fort Worth has MedStar, which has had a lot of problems with recruitment/retention lately. A lot of counties have their own county-level EMS service, or just contract with privates.

This patient needs benzodiazepines and may very well have paralytics and an ET tube on the horizon. None of which you can do at the BLS level.

BP, P, SpO2: those could have been gotten easily in my opinion... glucose check too.

Pulse...maybe. HR and SpO2 by finger probe? Sure. Blood glucose level test? That's expected...the standard of care. BP? Very funny. Try getting an accurate auscultated BP on an actively seizing patient. Tell me that heartbeat you felt wasn't his arm flailing around. And don't tell me that the NIBP your monitor gives you would be accurate.

As a BLS provider, the fact that there's not much you can do makes this situation pretty straightforward and easy. He's been seizing for 20+ minutes prior to EMS arrival, so he's hypoxic as all get out. NPA, BVM @ 15LPM, whatever initial vitals you can get, backboard, prompt ride to the hospital.

Wow, that's a lot of questions. I will try to answer them one by one.

The EMS system in Texas varies greatly (duh). The quality of care fluctuates depending on where you are. We have urban systems that run their butts off and rural volunteer services that rarely turn a wheel.

The majority of EMS agencies are fire departments. With that said, there are a good number of third services and private companies that provide 911 response.

Texas is one of the states that allows a medical director to specify your "scope of practice", the state sets minimums but doesn't explicitly forbid other procedures. This can create gray areas where rural BLS/ILS providers are authorized to perform procedures that are typically reserved for paramedics. You'll find the standard assortment of paramedic procedures/medications, lots of services have protocols for RSI, the more progressive ones are inducing hypothermia for post-arrest patients, the really spoiled places have things like transport ventilators and IV pumps (cough MCHD EMS cough).

You'll find that the vast majority of paramedic ambulances are set up as medic/EMT or medic/EMT-I, it's truly a luxury to work in a system with medic/medic trucks with both paramedics cleared to the same level (I'm spoiled). The only agencies I know of off-hand that do this are Austin-Travis County EMS and Williamson County EMS. Most services don't wanna cough up the $ to pay for that.

As far as "thinking on your feet" goes, it really depends on the agency. The ones I've worked for give you the ability to think for yourself and apply our clinical "guidelines" as you see appropriate. Other agencies make you call for orders for practically everything.

Hospitals depend on the area you work in. Obviously, the closer you are to a major metropolitan area, the better your choices will be. Some rural agencies may be hours from a basic hospital. Texas does not have a true "trauma system" compared to other states.

This is just my opinion, but I'd recommend taking your paramedic course here in Texas. Doing it in California will instill that fire-based, kick-it-to-AMR, call-for-orders-for-everything EMS mentality. Here you'll have the opportunity to ride with some kickass third services and learn to think for yourself.

Has anyone from abroad gone on an observer shift with the London Ambulance Service? I plan on re-visiting the UK in the next year or two and would love to ride along and see how the LAS works.

Help what? Carry a little old lady?

Anyhow, it's too late for that. I gave the firemonkeys "the shove" as soon as I got to the scene.

Somehow I figured that comment would come quickly I was kinda thinking about the difficulty of having to A) assist ventilations if this lady's sats and skin color are going to crap attempt more IVs/do an IO to get D50 on board vs. waiting to get to the hospital...with one set of hands.

Here's the scenario:

Female patient 80+ years old, called out for a fall. Fire crew (4 EMT's) arrives 3-4 minutes ahead of the ambulance, finds pt. on her knees facing away from the toilet, pt. had defecated on herself. Fire crew lifts pt. off her knees into a wooden chair. We arrive and find pt. with altered mentation (GCS 14, slow to respond, repetitive questioning), diaphoretic. Pt. released from a small hospital yesterday for a UTI.

Hx: HTN, CAD, no hx of diabetes

Meds: Levaquin (for UTI)

NKDA

Initial VS: HR 66, VS 130/90, RR 30, SP02 90% on room air, lung sounds clear, temp 98.6 temporal, BGL 43.

2 or 3 unsuccessful IV attempts, pt. says she can't swallow anything so oral glucose is a no-go. 1mg Glucagon goes in IM. O2 via NRB @ 15lpm. Sinus rhythm on the monitor. Move pt. to stretcher, move to ambulance. Get pt. in the back of the ambulance, SPO2 is now 72% with an NRB @ 15lpm, RR of 40, ETC02 of 25, 2nd BGL (~10 minutes after 1st one) is 33. Fingers are now cyanotic. With better lighting in the ambulance, you can now see that the pt.'s abdomen looks mottled. Closest (appropriate) hospital is 8-10 minutes away.

What would be your next move? Go ahead and transport? Take some of the fire guys with you to help? Just wanted to hear some different thought processes.

Bringing a large backpack and a separate trauma pack and digging through them for supplies in a confined space/vehicle rescue situation, while not spilling the stuff everywhere.

In-house FDNY slang shows FAST as Firefighter Assistance & Safety Team. One (Ladder) Truck company is stationed as such on arrival at an "all hands" or larger fire, as a standby rescue team for any other fire fighters who might "go down" during fire fighting operations thereat.

To the rest of the United States, that's known as a RIT team.

We use them as our primary packs. Each ambulance has two bags. The first (primary) bag carries BP/steth, glucometer, thermometer, King LT's, surgical airway kit, chest decompression kit, intubation stuff, BVM, bandaging stuff, and some first-line cardiac/anaphylaxis/ACS drugs, also has a small O2 tank and a small IV start kit (250mL bag). The second bag is for IV/med supplies. It has big bags o' saline, the EZ-IO, a bunch of syringes/needles/catheters, and a ton of drugs. They work fairly well. Seem pretty durable in the 1-2 years we've been using them.

What do you think of it? Did you get it stocked or empty?

I usually carry some stuff on a duty belt but our rescue turnouts negate that. I could clip one of these pouches onto the nylon belt of my turnout pants and at least have some basic stuff with me.

Anyone use one of these in the field? Interested in getting one for trauma calls/rescue situations. Something to have to stash some of the more useful trauma accessories (tourniquet, long IV caths, NPAs/OPAs, bandages, petrolatum dressings, shears, etc). I've found a few different models and I'm wondering if anyone has any experience with them. Call me a whacker, but our bags can be a huge pain to get through tight spaces, much less fish things out of them without spilling the entire bag into a wrecked car/tight space.

North American Rescue CCRK: http://www.narescue.com/Combat-Casualty-Re...Ind--P28C4.aspx

Pro Med Kit ALS Leg Pack: http://promedkits.com/als_leg.html

CUF Tactical Medic Thigh Rig: http://www.hsgear.biz/ProductInfo~productid~36-CUFTHIGH.html

I think I'm going to just order an empty pouch and stock it myself.

Our chopers have portable ct on them. They can do a quick xrays and see whats goin on in there. We have had them come in do that they decide its not major they pack up and go home we transport. SO if they get there decide that its major they take it or we take it. OUr area they just got a choper 35 miles away so they have there AUTO LUNCH established that there dispatch moniters ours and they make the call to auto lunch or not. If we don;t need them we just call um off

What's a "choper"?

Your "choper" doesn't have portable CT, you're thinking of portable ultrasound.

How can I get set up with AUTO LUNCH? It's hard to find time to eat around here lately...

Spell check is your friend.

Holy sheep I step away from this thread for a little while and it blows up :shock:

Let me clarify the following:

-The patient WAS transported

-The transport unit was ALS (all units in our system are ALS)

-The patient was experiencing a considerable amount of rectal bleeding

-The paramedic in question was in an evaluation phase for independent clearance and was "dinged" by his Field Training Officer, not by a supervisor

-A supervisor was never called to the scene or involved with this incident

We have protocols for the following IN drugs:

Fentanyl 1-2 mcg/kg

Versed 5mg

Naloxone 2mg

Glucagon 1mg

I've had mixed results with the fentanyl and versed. Haven't given naloxone or glucagon IN yet.

There's a lot of things that the rest of medicine is moving away from and we aren't. MAST, EOAs, lasix, coma cocktail....

There are services that still use EOA's? Yikes :shock:

This thread is getting good

True, and I will say the guidelines are focused on an MD level for in hospital treatment, not prehospital. What was in the references and a key point is that 80% of Gi bleeds stop spontaneously. With that in mind, 100-200ml's of blood is needed to create melena. But, if it bled more than that, it can stop, and melena can still be excreted until it has cleared the system. Taken a step further, the presence of melena DOES NOT ALWAYS MEAN CURRENT BLEED. That's the point I was getting at. Keep in mind that melena TAKES TIME to create, as it must be DIGESTED...if it was an uncontrolled large hemorrhage, then it would present as lots of frank blood from the rectum or hematemisis (WITHOUT coffee ground emesis).

Would you mind sharing your decision-making process for permissive hypotension vs. fluid resuscitation in GI bleeds?

Arizonaffcep, thank you for posting those links. It's refreshing to have someone back up their arguments with that much material!

Although the ACG Guidelines do specify fluid resuscitation, they don't mention a specific bolus amount, cutoff point, or target BP other than "euvolemia" and stabilized vital signs. So, am I infusing 20 mL/kg, trying to reach an SBP of 100mmHg? Smaller boluses (250-500mL) and attempt to maintain the pt.'s BP where it's at in the 90's? Infusing that fluid will increase perfusion and raise BP, but certainly won't help a clot form.

"The goal of resuscitation is the restoration of euvolemia

and resultant stability in vital signs. Resuscitative measures

include initial fluid administration via large bore intravenous

catheters. The amount of transfusion of red blood cells

and blood products must be individualized. There are potential

adverse effects of blood transfusion; the goal of

transfusion should be to minimize the risk of complications

due to red blood cell loss and/or correction of coagulopathy,

and not to transfuse to an arbitrary level of hemoglobin/

hematocrit."

Here's the thing though...even if the tarry stool started 30 seconds ago, its been sitting in his gut for a while digesting. Hence the dark tarry stool vs. frank blood. Even with hematoemesis, coffee ground emesis is indicative of a chronic GI bleed as well...other wise the blood would be undigested and unchanged. This means it's a small, steady bleed.

Understood, however the considering the onset of symtpoms and the amount of blood lost is important. Losing 1.5L in 2 hours vs. 18 hours...

I would guess that this pt is probably on HTN meds, and probably beta blockers at that. He's a truck driver (not ment to be profiling) but how many truck drivers do you know that eat well, get good exercise and don't have HTN?

This is true, they aren't usually shining examples of fitness and nutrition. I could see the beta blockers explaining a HR < 100 in the face of hemorrhage. I'm also curious as to how long the patient's been bleeding. Did he notice tarry stool the night before and now this, or BAM! did it start 30 minutes ago? (Forgive me for the Emeril refernce)