Odorono

This entire thread revolves around doing a thorough assessment, so your point here is really moot. If one spends their career being petrified of litigation, they will end up transporting every pt just to get the "What if?" questions out of their head, and thus contribute to the problem in EMS. The question in one's mind following a competent assessment should not be "Can I defend this in court?" but rather, "Have I made the best decision in the interests of my patient?" If one can answer affirmatively, then the former question shouldn't even be a consideration. This is exactly what we are talking about here, treating a patient as they present to us instead of rote doctrine compliance. Wendy was kind enough to answer all of your questions with an interesting scenario, so you should show her like courtesy.

This is kind of what fiznat and I are getting at; that mere consumption of a substance doesn't necessarily equal intoxication/ inebriation. And legality shouldn't dictate a pt's capacity to consent. Here in upstate NY, it's pretty much up the the cops if they will 22.09 a pt, which is a division of the mental hygiene law which states that a police (or peace) officer may detain a pt if they are determined to be intoxicated and unable to make their own decisions. This is selectively enforced, and seems to depend more on the officer's disposition than the pt's actual condition. While I still maintain that AZ laws seem particularly harsh, I think we all have statutes which compel us to transport pts under the influence. I think the more interesting discussion revolves around how exactly we determine whether these pts are influenced by their alcohol consumption. I've run into more than a few who have consumed a weekend's worth by my standards but can still maintain a quite coherent conversation. So are they intoxicated or not? Do we rely on field sobriety tests, or just a relative standard based upon our own experience?

Going before the regional committee next Thursday with my proposal, among others. Our medical director is on board, so if all else fails I'm pretty confident my service will have IN online soon for at least naloxone. Question for all those currently using it: were there any initial obstacles from the field medics when it was first implemented? I've heard some rumblings from others that IN is an affront to paramedics' ability to start IVs; just wondering if this is normal and what the responses were. Thanks to all...

Other tips for CHF: --Keep in mind that patients in dependent positions might present with sacral edema before pedal edema. Check the flanks and buttocks of NH/ sedentary patients. --Do a full assessment, and pay attention to hepatomegaly and do a quick check for hepatojugular reflux (firmly palpate RUQ for several seconds and observe JVD). --If you're on the fence and EKG findings are suggestive of ischemia/injury/infarct, lean towards CHF as secondary to ACS. --Lung sounds have been discussed extensively elsewhere on this forum; be familiar with the phrase, "all that wheezes is not asthma." --Also refer here: http://www.emtcity.com/phpBB2/viewtopic.php?t=2496

Holy crap! I didn't realize how draconian they made it down there. -5 for me thinking the Northeast was heavy on the legislation. Where I grew up, having it in your system wouldn't get you an MIP, only possession of the booze itself (same reasoning used by the idiots who eat their whole dime bag when they see a cop). Kids went to Canada all the time for exactly this reason. I absolutely understand and condone the DUI checkpoints at the border, but it doesn't seem sensible to penalize someone who has consumed alcohol legally in another country and isn't currently doing so. Does this lead to more kids staying in tacoland for the night to sleep it off, and does that lead to more trouble? Are these laws/ practices considered acceptable by the public? And while I am very familiar with alcohol's ability to alter mentation :wink:, my point earlier was only that it is dose-dependent, and more so than other illicit substances. No offense, but I'm glad I didn't go to college in AZ. Although one of the coolest sunsets I ever saw was outside of Scottsdale...

You're making two distinct arguments here. Your first statement implies that by breaking the law (possessing alcohol while under 21), a pt is suddenly unable to make decisions regarding their medical care. While to a certain extent this applies to a subject under arrest, I've never heard of anyone being arrested for underage drinking. I would be surprised to find your above statement supported in case law. The second argument is more variable, and I would be curious to read the actual AZ statutes. I can't imagine they would lump alcohol, a legal beverage, into the same category as those other illicit substances, since by that reasoning anyone who has had a drink has suddenly lost the capacity to make medical decisions. Capacity is not a static thing, and we should consider that when we speak with all of our patients. Capacity should be judged on a case-by-case basis, specific to a particular pt at a particular time concerning a particular treatment. DISCLAIMER: The above assumes we aren't talking about somebody who's totally gorked. The decision then is obvious. I am referencing those patients who have "ETOH on board" but are otherwise coherent.

http://findarticles.com/p/articles/mi_m0EI...25/ai_n27124869 These news releases are all over, but I can't find anything more recent. There was a study done in Iceland 8 years ago which used polyethylene glycol and did show some success in nasal absorption of diazepam. http://www.pubmedcentral.nih.gov/articlere...i?artid=2014600 Most of our Narcan comes in the 2mg/2mL prefilleds, but one hospital in the area dispenses the 4mg/10mL "family packs," as I like to call them. I'm not sure how much of a problem this will be, since each naris can accommodate up to 2mL of atomized medication, which means you could get up to 1.6 mg into a pt with the more dilute solution. And as firedoc315 pointed out, rapid depression of the plunger is necessary for atomization.

My apologies if our signals got crossed. I may have been projecting several situations which have recently happened to me onto your statement, although I still stand by mine. I think the issue is really how to define intoxication and who decides if the patient goes to the hospital. At the risk of hijacking, I'll stop there, although cops giving pts the choice between the hospital or jail is probably not good pt care.

Awesome. I've spoken prior with several down-staters but they were unaware of this. I read the remainder of the protocols; do you know why narcan was the only drug approved for IN? Have the medics been using this option?

I'm trying to implement intranasal medication administration as an option in my area, and am looking for some additional research. I've found the Denver and Australia studies using IN naloxone, but have yet to find anything in the prehospital arena for other drugs (especially midazolam but also glucagon and fentanyl). Anecdotally, how have those of you who do use it currently found its efficacy, and which meds are approved? Most importantly, does anyone know of any services in New York State (air or ground) that currently use IN as a treatment modality?

Big problem with this statement. Are you implying that you coerce patients under the age of 21 to go to the hospital for fear of LE involvement? If you have a patient who you feel must go to the hospital, or does not have the capacity to consent, then LE is a definite consideration for your own safety. But I fail to understand why this should apply any more to an underage drinker than another patient. If the kid is CAO x4, normoglycemic and the circumstances of the evening are clear there's no reason to call the cops just because he's under 21. I'm with fiznat on this one, and I think blanket statements or protocols specifying transport in the mere presence of alcohol provide a great and unnecessary burden on the entire system.

The "saving lives" claim has got to be one one of the most crippling factors in the advancement of EMS as a profession. It's the salient underpinning to almost all forms of whackerism. If we admitted to ourselves that we "save" far fewer lives than quite a few other professions then I think EMS would begin making great strides toward the legitimacy we all claim to seek from many of those same professions. Although I fear the Saving Lives dragon may be even harder to slay than the Fire-Based EMS one...

Thanks for the prompt replies from everybody. I've PMed most of you and found it helpful, although I would love to hear more from anyone about the Denver area, especially Pridemark or Denver Health, as well as any other places nationwide which might fit with the OP. Man are you NC people enthusiastic though!

Gotcha-- I suppose as long as both are simultaneously dispatched and scene time isn't delayed to wait for the BLS, this isn't too bad. Especially since some of those on the BLS bus may actually be medics acting in a BLS capacity, correct?

Sorry Dust-- I have no knowledge of Boston and only cursory knowledge of NYC. Maybe RichardB can fill us in, but I wasn't aware a FDNY medic on scene would actually call a BLS bus or voluntary to transport, especially since the hospitals are so close. Of course, if every ambulance in this fine country was ALS, this would never be an issue...