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...

While I normally feel pretty strongly about volunteerism in EMS, this article didn't really bother me that much. Perhaps it's because I recall the author from my days further upstate, and he struck me as a rather calm and capable basic in a service that was decidedly not (Their "chief," who weighs about 450 pounds and wears padded suspenders everywhere, has recently taken up bicycling, which can usually found in the bed of his giant red pickup truck that also serves as a NYS-certified BLS QRV and a snowplow). Either way, I can see how this article could be misconstrued. Keep in mind, he wasn't writing it to give the public an expose into the world of EMS-- he was describing how his days off are different from most others'. As asys pointed out, much of this is written to be palatable to the greater public, and if we all looked through the oxygen-fueled flames, we could see that he finds some interesting things to say. He talks about how quickly he lost the impression that we just joy-ride and slap Band-Aids around, which is definitely one view the public has of us. His "juxtaposition between serenity and chaos" was one of the reasons I chose EMS, and I'm sure many of you can say the same at some point. And he leaves the reader with the firm impression that gory tib-fibs are not what it's all about; that ultimately the most meaningful calls are the least dramatic. Many will fault the author because he's a volunteer. But the guy's got a PhD in English. Why should it make a difference whether he gets paid a paltry sum for that one shift a week or just works it because he wants to? Most importantly, keep in mind that this is a pretty complimentary article that, while it may often be fluff, DOES serve as a counterpoint to the other stories in the news about EMS. Like it or not, we actually need more stuff along these lines. I'd work with him.

Going back to the whole issue of ALS transport showing up on scene and then calling for a BLS ambulance to take the patient instead-- I have no first-hand experience with this and it seems quite ridiculous to me. This seems to be more of a Western/ Southwestern phenomenon. Where did it come from? Is it because local FDs have a lock on ALS staffing and then get lazy and private companies are looking to make money any way they can, or is there a more rational explanation? Another topic brought up the current economic crisis and the possible impact it could have on all of our jobs, whether city, county, hospital or private. If EMS begins to face greater scrutiny regarding efficiency and cost-effectiveness, how is a practice like this going to help us justify our field?

It's difficult to really Monday morning QB this entire situation because there is a lot of information we don't know that the monkeys might have, especially the size/ nature of the weapon and circumstances surrounding the actual injury. Perhaps the issue was not so much the possible acuity of the patient (or lack thereof), but the inability of the crew on scene to communicate this to the doc. But this is not to be construed as a defense of the firemen, because had they just thrown the patient in the back of their rig and gone to the hospital on their own and not asked for a BLS rig, there probably wouldn't have been any issue. Any system that gives transporting ALS the option to turf a pt to a BLS unit that hasn't even been dispatched yet is going to run into stupidity like this.

Really... Which ones? I grew up in mid-Michigan and would love to be back in-state but haven't found anything that either pays well enough or is a place I'd like to work at. Are you talking UP or northern LP? And what about these services impressed you?

[/font:c2cfcbbde5] I'll start by saying hello since I've been a long time lurker but never had much to say that wasn't already said. I come for advice, since I'm another one of those new medics who wants to relocate. I've been in EMS for about 5 years now and finished medic school at an accredited, nationally recognized program in May. I returned to my old service in upstate NY to have a familiar environment to begin practicing in, but I never intended on staying. I've been reading the posts from others looking for advice but want a bit more. I'm looking for the ideal combination of 911 volume and progressive protocols, and perhaps more importantly motivated and intelligent coworkers (at least a few). I'm an avid snowboarder, so mountain access would great as well. Been thinking aboutv Denver but I know knothing about pay or protocols. Is there anything further west that avoids the hose jockey paradigm? And what about somewhere like Albuquerque or Flagstaff? While I generally like four seasons and lots of snow, I've also been considering NC (specifically Charlotte and Wake Co). I know Wake has great protocols, but can't find anything on Mecklenburg County. Sorry this is so scattershot but I'm prepared to go just about anywhere in search of a decent job in a cool city. Thanks in advance.