scratrat

The bad thing is if you don't have a signal, you're screwed. And hopefully not in trouble. The good thing is if it works, you can hear everyone so you're not stepping on anyone. I also found out (I don't know if this is just our particular system or what) that only a certain number of frequencies can be used at any given time. Like, even though fire, police, and EMS are on different channels, only 8 combined channels can be used at once. My radio will not work at all if I'm number 9. That means if 4 police officers are talking on different channels, and 4 firefighters are talking, I can't. I don't understand that since it's different channels.

We used it in NJ and it was pretty good because it was less urban where I worked. You could talk to one end of the county to the other, unlike VHF.

That's all the same here. But my question is, do you mix it in a soft bag or a hard plastic bag? We carried both. One bag was stiffer than the other.

Question.....

When we first starting using amiodarone in NJ, we were told to mix it in a hard bag of D5W. We were told that you were not allowed to use a soft bag because it caused the amiodarone to leach the PVC out of the bag and into that patients circulation.

Here if FL, we used those same hard bags. For whatever reason the stock person got the soft bags, and was told thats all he could get because the others were on back order.

I tried to find these answers on the internet but to no avail. The only thing I found states that this problem only occurs at doses higher than recommended or longer than recommended. I also found that this seems to be more of a problem with pediatrics. The only other thing of significance was that amiodarone loses the drug properties within 12 hours or so when in plastic, but not in glass.

Anyway, my question is does anyone know if it's been proven safe to use soft bags of D5 or do you use hard bags/glass to administer a drip of amiodarone?

That's just funny...

Yes, I am sure. I came from snow land.

Yellow is the first color seen in fog, rain, snow, etc. Blue is second.

Line up three lights spaced about 2-3 feet apart and close your eyes. Open then and see which one gets focused attention first...

Actually, the first color the human eye can detect in all weather conditions, would be yellow/amber, hence the law that all ambulances have a rear amber light. Then blue, then red. Clear is just obnoxious. We have all LED lights and there are three red and two white on the front of the box. They are pretty obnoxious, but not as bad as standard incadescants.

That is so AWESOME!

I love it!

Oh, I see mwhy I said that. A couple of people asked about the ECG and you must not have seen that so you didn't reply. I had thought you did. That's why I was surprised at the ECG. Two people asked about it but you must've missed that. Oh well. Thanks for the good scenario!!

HOLY CRAP!!!

I thought you said earlier that the 12 lead was normal???

That would an inferior MI c/ lateral extension.

Or, commonly called, you gonna die!

adding more tequilla

Since you're not allowed to split crews (which would in effect give you two ALS trucks). The only problem is that how can a Paramedic (even if they're only working at BLS level) pass off a pt to a BLS crew?

It's stated in my state protocols that patient care can only be transferred to someone of EQUAL OR HIGHER licensure.

I notice that the parameters that govern the transfer of patient care do not specify or make allowances/exceptions for the level of care given at the time of transfer.

In New Jersey, you could not split. They eventually allowed it under extreme circumstances. IE, accident scene with 2 ALS patients and the second medic unit is 20 minutes away, while the helicopter is 10 minutes away. You cannot operate an ALS unit without two certified paramedics on board. If you did split, I guess technically, you were operating as two units, however, you could stop at another call and treat someone, or just take it upon yourself to start treating a second patient. Especially while enroute to the hospital. You requested a second unit.

On the other note, ALS could in fact hand off a patient to BLS. We were allowed to evaluate the patient fully. We called medical control and informed them that we felt our services were not required. We gave them a full history and report. Either they agreed and BLS transported and we went available, or they disagreed and told us to treat with the IV of life. They called that Triaged to BLS or SNR. (Services not rendered.) Example would be when the local dispatcher calls us for a stroke and it turns out to be a 21 year old with a headache. We could evaluate and traige back to BLS provided everything came back okay during our assessment.

If you were treating an ALS patient, you could only transfer to another medic unit or a registered nurse at the ED.

Now see, ERdoc, I was going with sepsis because of the recent pneumonia and slightly low temp. But you keep throwing that damn plavix out there, obviously as a hint. Now I have to go do some research....you bastard you...

Again scratrat, you are speaking from the perspective of your current system. If you moved to a system that didn't follow these rules (like mine), your opinion will change. If you held these views tried and true, you would not be able to function long in my system. Maybe we play in a more subjective system? Judging by the posts here it appears we do. Again, as long as I can rationalize and it is reasonable...

Why can't an ALS crew hand off a BLS patient to a BLS crew? Especially one that you're babysitting in hospital? Again, this happens many many times daily here...

That's how every place I've ever worked at operated. The only time we actually stopped was when my idiot partner nailed someone at an intersection. Any other time, you call it in and keep driving. I feel you are obligated to. But I guess thats just me.

I never said ALS couldn't hand off a BLS pt. That was my point. Transfer to EQUAL or greater medical authority. You could certainly do that.

In New Jersey, we weren't allowed to split, like someone else mentioned, I think from Texas. If we had two ALS pt's, you could begin treatment but you had to call a second ALS unit and transfer to them when they got on scene.

Scrat, following protocols is often what saves you in lawsuits. If you saw the gun was out and then tried to stop, that would be ridiculous. But if you have a stable patient in the back and stop to help, you'd be doing exactly what the state wants you to do. The liability falls on the state. That protocol was written exactly to tell you to stop even if you had a stable patient in the back.

It'd be different if you had an exception or some reason why you should have disregarded that protocol, but not only was there no exception, but it was specifically what the protocol was written for.

Also, we were taught you could be in trouble for abandonment from the moment you're dispatched to the call, even if you haven't made contact yet. Seeing the accident and having standing orders to stop, then you've already been given that person as a patient.

I was never taught that. We are rerouted all the time for other more priority calls. The dispatch someone else to the less severe call.

But I still firmly believe it's abandonment if you do not continue to transport your patient to the hospital or at least transfer them to someone else of the same or higher certification.

I respectfully disagree.

You already had a duty to respond to the first patient. Your duty to this first patient does not end until you transfer them to the hospital or to another ambulance of equal or greater level of care. You cannot abandon your initial patient. Once you initiate that care, you are bound to see it though. Unless you haven't made patient contact, you cannot leave.

Some of you may say it's abandonment not to stop, but I don't see it that way, and I don't think the courts would either. If you already have a paitent, your only duty to act would involve calling it in to dispatch and advising them of the situation.

The only time I could EVER see a deviation from this, would be an MCI.

I am also curious to see if the family sues and what the outcome will be. If that were my kid, I certainly would have someone's arse on a platter. They directly put my kid into a line a gunfire. That is unacceptable.

dalhio wrote:

(a) All pronouncements of death shall be made in accordance with rules promulgated by the State Board of Medical Examiners and with the physician's medical judgment

And the rules are?

In New Jersey :

A paramedic may pronounce via telemetry to medical control.

Pt must present with :

Asystole in at least 3 leads.

Although it also specifies ANY pulseless rhythm, most medical directors specify asystole.

No spontaneous respirations.

Any of the following :

Prolonged down time (not usually specified but 20-30 minutes is fair game)

Lividity

Rigor Mortis

Obvious decapitation or mortal wound

Pupils fixed and dilated.

It isn't specified but it also helped if the pt was under the direct care of a physician and had some sort of medical condition.

You could also do a DOA - not pronounced. However, with the lazy arse medical examiners office, you would be called out later for the sole purposes of a pronouncement. These were cases where you walk in and find a head missing from a shotgun blast, or someone not seen you two weeks, and obviously died two weeks ago. Again, the medical examiners office would call you back anyway so it was easier to pronouce.

I once had to pronounce someone who was missing half their head from a self inflicting shotgun to the head while the ME investigator was doing a liver temp. How screwed up is that? But that's for another forum I guess......

On the the original question

It does sound like a lot of information is missing. Might I ask where you are from, roughly speaking. Depending on the MICU service, I'll reserve comment. If lividity was present, or rigor mortis, or pupils were fixed dilated and glazed over, I would have pronounced. But thats just me. I know some medics who never pronounced and worked everything regardless. I also knew some medics who pronounced no matter what. If the squad shocked three times as they were walking in and the pt was now asystolic, he would pronounce. Nothing in writing says you actually HAVE to stop CPR efforts. At least not in New Jersey, save for a DNR of course.

I smell poo poo......

In California, violating protocols, would be against state law. If I had special circumstances, that'd be fine. This scenario would not qualify, as it's exactly what the protocols would have been created for.

Also, my understanding of abandonment is that you must have a duty to act. If protocols say you have a duty to stop (I know yours don't, but you originally said you would keep going even if protocols told you to stop), and then you don't, you're getting into abandonment of driver of the accident.

My whole point is that it might not be 100% clear-cut and it's not a whacker issue.

Allow me to elaborate on whits post if I may :

Abandonment and Negligence

Terminating care of a patient without making sure the patient is in the hands of a provider at the same or higher level of training is considered abandonment.

Negligence is deviation from the accepted standard of care that results in injury to a patient.

There are four components to a successful negligence action

or lawsuit:

*The EMT-B had a duty to act. This means that the

E M T-B was in a situation through employment,

position in a volunteer squad, or other position

in which the EMT-B is re q u i red to provide care

and . . .

HERE : The EMT/medic had a duty to respond to the seizure pt. They responded and had that pt on board the ambulance. This part they did correctly.

* The EMT-B breached, or failed to perform, that

duty and . . .

HERE : The EMT now breached, or failed to perform. He was expected to transport someone's sick family member to the hospital. He was no longer doing so.

* Injuries, which may be physical or psychological,

or damages were inflicted and . . .

HERE : Being shot at? I'm going to go out on a limb, and say this definately fits this criteria.

* The actions or lack of action caused the injury or

damage.

HERE : Actions caused the injury. Um, yes. The driver stopped. He is directly responsible for the action that caused them to be shot at.

Now on to the abandonment aspect of the issue.

Abandonment of a patient, in medicine, is where a health care professional (usually a physician, nurse, dentist, or paramedic) has already begun emergency treatment of a patient and then suddenly walks away while the patient is still in need, without securing the services of an adequate substitute, or giving the patient adequate opportunity to find one.

hmmmm...sounds like abandonment to me. You did not secure further treatment for this individual by taking them to a hospital. Services were no longer being rendered because you were no longer transporting that pt to definitive care. Sounds like a win-win situation in a court of law.

On to your next comment.

In California, violating protocols, would be against state law.

Your protocols prohibit you from continuing patient care?

Protocols are guidelines and nothing more.

I realize that everyone is set against "what-ifs" but I have to do it in order to make my point.

Same case, only this time you stop at the scene. The driver gets out and shoots your pediatric patient then takes his own life. You stopped because your protocols say you must stop at an accident scene, even if already treating a patient.

Now the family sues you for wrongful death, and possibly negligent homicide (but I'm not sure about that one). You will definately be sued for the first one.

Do you think a court is going to say, "Well, Mrs. Jones, we're sorry that they placed your child in harms way and as a DIRECT result, you're child was shot. However, their protocols say they are to stop and render aid."

Let that one sink in for a minute. Then tell me, honestly, protocols or not, do you think for a minute the court will side with you or with the mother whose young child was shot? Sorry for the horrible scene description that I'd never wish on anyone, but this could have been a real possibility.

As Dust says....if you protocols say that you are to stop no matter what, then your system sucks arse. I think I spelled that one right for you Dust.

Oh, I WANT one!! Here's why.

I only want it if:

1./ It can be filled with Haldol and Benadryl

2./ It can be fired from 25 feet.

Now that, in the words of Bill Engvall, would be AWESOME!

You never stop. That's abandonment. I don't what anyone says.

That first pt was sick and requested transport to the hospital. They expect to be transported. If the ambulance was involved, then that'd be different. But in this case, they should have radioed it in and kept driving. The only time I've ever stopped, was on the way to the call. Never after a pt was on board.

My take:

Do you want to go to the hospital?

Yes?

Good. Get in.

Done.

I had it all. Lights, radios, lights.....

I became an EMT when I was 17 so I went ape. Everyone in high school thought my EMT book was neat with all the pictures in it, so I fed off that.

A couple years later, I went to medic school. I think the big difference for me, was this was more professional of a career than being an EMT in that state. There is no such thing as a volunteer paramedic where I went to school.

Plus all the true whackers would piss me off to no end!! I hated it when they'd all show up on my duty night for the MVC. No one could help with the pt, because they were too busy listening to themselves on the radio. Then, those same ones would be no where to be found when the little old lady fell. And a few hours later, they'd show up at the next MVC. AAHHHHHHHHHHHHHH!!!!! That was my last day in a volunteer rescue squad.

Is this a scenario, or are you trying to brow beat everyone into agreeing with you?

What do the protocols say. That is what matters. If "B" is the only trauma center, and your protocols say go to hospital "B" that is where we are going. This patient can not be guaranteed to not have an altered mental status. Did you know him before the accident? Your liability rests on the protocols, not on your heart.

Um no.

Protocols are GUIDELINES. If a patient is CAO x4, guess what? Your protocols don't mean jack. My protocols say I give NTG to someone with CP. What if they refuse? After I determine they are CAO x 4, I'd make sure to explain why declining NTG is not in their best interests. Then, guess what? They don't get it. If they tell me no, it's assualt to do anything otherwise. You cannot force your protcols on anyone who is not incapacitated.

And yes he can be guarenteed to not be altered. Do you know your name, age, location, present events, year, month, etc. etc. Is he NOT under the influence of alcohol or drugs? If you can answer them correctly, guess what? You're CAO x 4. Not to start an argument, but if you took this guy to the hospital he didn't want to go to, you're now charged with kidnapping.

Here's my shot in the dark.

A single long bone fracture isn't necessarily a trauma. Any hospital with a orthopedic surgeon can fix it. The only other problem is, how can you be absolutely sure he doesn't have any other injuries? He could have c-spine issues. And if that hospital can't handle those injuries, then we have a problem. But if he is transported to the local hospital of his choice, it's better then nothing. Maybe they can fix his leg, then convince him of the need to be shipped elsewhere.

That said, Id explain the risks of going to XYZ hospital vs. ABC hospital. Then if he still wants to go to XYZ hospital, then that's his wish. Just because he has an injury doesn't mean you can force him to go to the hospital that your 'protocols' says. For example, it is state law that we transport to the only certified stroke center in the area, if pt presents with possible CVA. However, that pt, or their PA, can request the other hospital. They are informed of the ramifications, and must sign a form signifying that they understand that the other hospital cannot properly manage them, and they may die. Then we transport them. Until they are unconscious or confused, then you have no say in where they be transported.

Both of our hospitals are cardiac centers with a cath lab.

Only one is a certified stroke center though. And by State law, we are required to bring any suspected stroke to that hospital, regardless of what the pt wants.