Krysteen

Interesting topic:) Actually had the exact same patient presentation. Bottle of benzos empty. Note written. Pt unresponsive. Gave romazicon per protocol and was later pulled aside by ER doc and was informed that treating benzo overdose with romazicon has changed primarily because had my patient had rebound seizures, which has become increasingly common, I would have had no way of treating them. This was one of three times our service was warned, each a diff medic, in the last six months. So we we have since changeed our protocol for use only as a adjunct to our administration of benzos if reversal is warranted.

I agree,AAA. What caught my eye was that I had a pt that presented exactly the same with lower back/abd pain that radiated to the groin area, hypotensive. This too was an AAA. Pt survived however.

Not too concerned if someone wants to nail me for what we did. I'll gladly take the punishment- and would do it again in a heartbeat. I would hope someone would do the same for my mom in a similar situation.

Would gladly=) I have also given rides home, generally to the elderly.

All I have to say is, never underestimate those little rural ERs. You have to be good to work there. You don't have every specialty to back you up when the shit hits the fan, you actually have to be a doctor.

Nice! and true! I have worked under some fantastic rural ER docs. Have no clue how they do it though, I will see them up all hours of the night only to have to work clinic in the morning. I have brought in some pretty nasty stuff and you're right. There is no trauma team, pulmonary team, surg team at their disposal. I also have the privilege to be able to have one as my med director. Always nice to be able to have a close working relationship with your director and receive feedback immediatly on your treatment decisions.

As far as books your class list is best to go off of. However, one book I purchased on my own and still pull out til this day is "Rapid Interpretation of EKG's, 6th Ed., Dale Dubin. I'm more of a cardiac kind of girl. Kudos on deciding to further your education:)

Krysteen,

I think it's brave of you to put this out here. It is a classic situation where you have your back to the wall. I don't do RSI either, so I would have been facing the same problems. I have been in similar situations in the past but have usually been able to manage the airway to an acceptable degree with a BVM. I have never done nasal intubation (it's not taught here) but it's an interesting option. MY only other option would be to cric the pt. TO be honest, you know it's a last ditch thing but who really does have the guts to cut open someone's neck? I never have, in any case.

WM

You mean everyone else's calls are 100% perfect everytime?

Dwayne, loved hearing about your NTI experience. We use the BAM as well and I really just pictured you waiting oh so patiently for the next whistle on a RR of 6.

No offense taken here on the halfassery comment:) Beat myself up on this call enough. Usa, you said so yourself you have that luxury of RSI. I on the other hand do not. There was talk on RSI and utilizing it. Here were my thoughts and you can do a double take, I know my limitations. For as much as I would love it in situations like these, unless I can guarantee a spot quarterly in the OR keeping up those skills and that I have a Paramedic partner to assist I will pass. Now with that being said I have heard the largest ground EMS agency may be losing that privilege due to misuse. Which isn't good because I could use them as intercept. You never know what you are missing til its not there anymore.

Dwayne you are my hero:) I am quite close to your location also. I enjoy reading your posts, learn, and agree with you on many scenerios. The patient exhibited cheyne-stokes. Classic Cushings Triad, not sure if I will ever come across it again. Thank you for saying this call sucked.

Here is what happened. Risk of aspiration was already there. Vomit was being expelled through clenched teeth of what may have been beer and pizza for all I knew. I know that versed most likely would not have the effect I wanted on the trismus, but it was worth a shot. Pt was already vomiting when I grabbed it. I was debating nasal intubation, and chose not because of head injury. So I pushed a little versed with no effect obviously. All I could do was roll the board and suction. Pts vitals did not change significantly. I informed them no definitive airway, and that I do not have RSI capability. First thing asked was, "did you administer anything to facilitate intubation". At least I was able to say yes to that.

Dwayne, per my medical director review. He said nasal would have been the choice. He would have backed me on that one. Now it depends on which doc you ask. All have different opinions. Now, if I am ever presented with this again I know which route I am heading. This also lead to a Trauma Review with the receiving facility. I was terrified, but in the end the ER also had their struggles. The physician on review did not agree with nasal and not once was cric mentioned. Versed was just a waste as I held back on giving enough to possibly see any effect. The end thought was to request for intercept of the said agency above.

I was ready to take an ass chewing, but to my surprise I was commended on what we Paramedics face out in rural country without a controled environment or a trauma team at our disposal. This patients prognosis was poor even before I arrived. On a good note, this patient may have saved lives as their organs were donated.

Wrong diagnosis, wrong treatment, lack of treatment, medication errors, failure to treat. I am sure I am not the only one who has witnessed this problem.

I didn't realize medicine was so cut and dry.

Sounds like the medic refused online orders. Big problem. As far as reporting errors, I'd tell the receiving facility and document. I am not the one to call the family. My pockets have holes in them as it is.

I had a similar case. However, patient was middle aged, awoke in the night to tongue swelling. They complained of tightness to their throat and voice a little hoarse. Only swelling was to the tongue and quite significant. I by no means am aware of ACE inhibitor reactions. Worth researching, however. Patients BP slightly low, PR was within normal limits. No wheezing present.

Per protocol, I chose the allergic reaction route. Started fluids, administered diphenhydramine IV and Sub Q epi. Upon arrival at ER, they continued epi as well as another dose of diphenhydramine, prepared for RSI, and patient was air lifted to a larger facility. Based on their reaction I felt I did well.

Interesting as I kept thinking what this person could have reacted to as they were asleep. Think the call came in midnight or so. I questioned some sort of bite maybe, new medications. I cannot remember the list of meds they were on and did not hear of the patients outcome.

Very relaxed protocols on pain management. I start with fentanyl for faster onset and will usually continue with morphine. Also we have abdominal pain management protocols. The old treatment of absolutely no pain control has been done away with here for quite some time. I refuse to let my patients suffer.

HLPP, could you present a similar situation where you have had to weigh risk/benefit in airway management. With all do respect I have read your posts and am under the assumption you are a non-emergency transport service. Sure the risk is there for a potential non-emergent situation to turn emergent.

I have scenerio I will present and please others weigh in on this one cause it still haunts me. MVC ejection. Both your air medicals tied up. Trauma center 45 min out. No obvious external injuries. Pt gcs of 5, unequal pupils (one blown), patient showing Cushings Triad symptoms. Airway suction needed. No vomitus (yet), pt has clenched jaw. Your attempts at sunctioning are minimal, you are able to pass the catheter through an approximately 2-3cm opening, this opening could allow you to pass a laryngoscope, but would in no way allow you to visualize the cord. How would you manage this airway? You do not RSI. Your prayers to meet up with medivac go unanswered. Patient begins to vomit large amounts of chunkyness.

Dwayne, absolutely I would agree on transport time. If arrival at hospital is ten minutes I will assist with BVM, but for me if I am 40 minutes out I will consider intubation. We do not RSI but I might have used versed as an adjunct in the way this patient presented.

I mentioned that I also transport multiple patients on the patient advocate thread. As a matter of fact, when some others said absolutely never I paused, but then again I am in Rural EMS, what else am I to do? I have two ambulances, that is if anyone responds for the backup. Two Paramedics staff the primary rig 24/7. We ask that our EMTs answer for backup if they are able. So at most we could transport 4. I did work in an ambulance where the possibility to "hang" a patient was there but never used it, seemed a little unstable. We cover 240sq miles, but have zones where we have non-transport units that are dispatched because our on scene time could be up to 25 minutes. Nearest trauma center is around 40-60 miles depending on incident location. We have access to two air medicals. Last two potential scene flights I had, I really really wanted them to come but both were unable. We have the option to transport by ground to the most definitive care, Paramedic discretion. Otherwise, there are 5 other small hospitals they could be diverted to. There are other ambulance services, response times probably 25-40 minutes, who may come for mutual but generally if we man both our ambulances we will not request aid unless we have more then 4 patients.

I will also add that the "other" ambulance services are three very small volunteer services who have limited resources, and one paid full-time service which staffs only one ambulance each shift.

I am going to start my EMT-B course in January, what steps can you take while defending yourself? I`m sure there are things you can do only in certain situations. Is it up to the state that im in? I know that its an all too common part of the job for things like that to happen, did anyone have a problem keeping their cool in some of these situations? If you did, how did you handle it?

Essentially, for me it begins at scene safety. I never enter a scene where law hasn't cleared it first, such as an assault call. If at anytime I have felt in danger, I have left to a safe distance until law arrives. Even if that means leaving your patient. One instance I had a family member becoming aggressive towards me. It was one of those I allowed the person to block my only exit, he was not complying with my requests to wait outside, and once he came toward me, began threatening me, I made my escape and called law for backup.

We can do no harm to our patients. Even our restraints are padded as to not hurt them. In my experience, my next step is applying soft restraints, that is if law has not cuffed them first. It depends on your protocol, ours is pretty liberal. Now in my protocol, the way I find most these patients they also end up backboarded as I can't rule anything out. Another backup to restraining, works well, but even they can wiggle loose from that. Just have to really monitor their airway.

I can easily say I have applied more restraints then say given ASA for chest pain. That's just our common problem in my area. Pretty sad. Then there is also chemically restraining them, when and if you decide to become medic:)

Boy would I love to have some other means of defending myself like a taser! But unfortunately, that will never happen. Like I said, for the most part I have been doing this for 8 yrs, this has worked pretty well so far. In this case, I was taking c-spine on a patient. I was in the direct path of the "slime". I immediately backed up cause to me saliva can be just as deadly. LE intervened. Pt restrained, and I had to go on as if nothing happened. Sucks but that's the way it is.

You HAVE to keep your cool in this field. Not only applying to instances like these but everything you encounter. To me that is probably the most important quality an EMT must have. Everyone is looking for you to calm the situation, and if I look "freaked" I have just made a bad situation worse. Inside, yes, I feel all the emotions. I just keep a lid on them.

HERBIE, I think your right for my area. That is pretty much what I was told verbatim.

Hey thanks for all the replies. I think I really needed to vent a little. In the meantime, as I would love to update, the plot has thickened. When I'm able to share more of my experience and outcome I will.

I am the one being attacked here, as far as my management skills go, feel free to attack, but as a manager I have to enforce all policies fairly, and we have a policy that does not allow the medic to refuse a call. You can disagree with the company's stance, but that is our policy. And I disgree with most people's answer that a safety concern can be variable and open to interpretation. If you refuse to transport this patient due to MVC concerns, then I say you can not transport any patient, as no patient is safe in the back of an ambulance during an MVC, the stretcher will come loose from the floor, the plexiglass and all supplies will become airborn missles. You can't have it both ways.

Is there a misinterpretation of this policy? There is a difference in refusing a transport because your shift ends in ten minutes. I suggest changing or modifying that policy. Be a little proactive here before you are in the eyes of the public when something terrible goes wrong.

HLPP, I can see where you feel attacked but also constructive criticism is an excellent learning tool. I have been there:) I am curious though as to what the outcome of this employee would have been had there been an MVC involved? Is it kind of like a damned if you do damned if you don't situation? Would you have your employees back then? Not that it would matter because they may face their licensing board, the ultimate authority.

For me I would rather have my day in court saying " I felt that my patient was in need of urgent medical care and the benefits outweighed the risk then; my boss says I can't refuse a transfer and I just "figured" we would not be involved in an accident."

As far as the backboard on the bench seat, sure do. My ambulance has three safety restraints there for that reason.

OP, I would have commended you on your critical thinking. To blatantly put that " I would fire you" is a reflection of my poor management skills. I have unfortunately worked under those types in my career and I would love to put on my resume I was terminated solely due to the fact I had my safety and my patient's in my best interest. I am myself a manager for a governmental agency both 911 and transport. I could put it up on my profile, but frankly I don't put myself up on a pedistool. I rather apply my managerial skills in a more effective way.

Hahaha, love the idea of a taser. In my toolbox though, I only have a mask, soft restraints, a little ativan, some valium and haldol, just was not within arms reach (in the rig of course). I always wear gloves, but I do not walk into every scene with a mask, gown, and eye protection. I always identify myself. Within minutes of pt contact, I had to wipe saliva from my face in all the "oh Hell no u didn't" areas. ETOH likely involved. I am well aware this comes with the job, which I thoroughly enjoy and have worked full time for 8 yrs now. This is a case of: I let my guard down, a lesson to myself and to all. The total violation and disgust you feel is terrible, but then you gather yourself and your thoughts (however disturbed they may be), continue on, and treat them with respect and dignity as a human that you were denied.

If you choose to become intoxicated, you should also be ready to deal with the choices you make and their consequences. In the eyes of the law, EMS should be considered a public servant in all states, afterall we do serve the public.

I have been swung at, spit on/at, groped,you name it. I have been fortunate to have a faster reaction time then my patients or to not be caught off guard except for one. My question is to those who have been in a similar position to being spat in the face. Were there any charges or conviction to your patient against you, or were charges dropped. I know there is a law against public officers. Are we in that bracket or just another civilian? Please share your thoughts or experiences.

A pen, watch, a cool calm demeanor, and the willingness to learn.

I have been inactive from this forum for quite some time and occasionally receive emails on "emt city misses you". However, this morning I received one on the passing of DustDevil. I came to pay my respects and I am quite sure "emt city will miss you" tremendously. I was a lurker mostly with a few posts here and there, but truly enjoyed reading his posts. Hats off to you and may you RIP ems brother.

There is plenty of research out there showing that the concern of limb loss or massive tissue destruction caused by tourniquets is urban lengend, the fear of causing harm is causing harm.

Never once have I ever been educated that the dangers of tourniquet application are just urban legends. However I have been taught that the risks increase if the time from when the application is applied to definitive care is beyond 90 minutes, meaning application to surgery. Are you able to provide some information on this research?

the safest approach in the case of the marginally trained and inexperienced person with basic first aid training is probably to rely upon simple direct pressure or basic forms of pressure dressing. This is due to a lack of evidence that such persons can effectively recognize the need for a tourniquet and properly apply such a device- especially given the likely need to improvise under such circumstances.

Unless they are properly trained to recognize the difference between a strong venous or arterial bleed, and how to properly assess after the fact, especially in the rural setting, this can be dangerous. I can see the fact that they can "do it", will lead them to just do it without proper assessment.

The rapid employment of tourniquets may also provide an opportunity to improve the prognosis for those who might otherwise not receive care due to the severity of their injuries in a mass casualty situation where triage principles are applied. The expedient control of extremity hemorrhage may allow a few of these patients to survive long enough for them to be evacuated even when a medic may be forced to move on to another patient due to prioritization.

I do not disagree with the application. As in instances such as above, the benefit will outweigh the risk.

The use of tourniquets, while beneficial to many of those wound in combat or with otherwise uncontrollable bleeding, is not without its hazards and potential complications. Any use of a tourniquet must be with full awareness of the risks involved and to brush these aside would be to abandon one of the basic tenets of evidence based medical practice.

Exactly, all stems down to proper education. Which is not at all on the top of the list to some places these days. See http://www.emtcity.com/forum/index.php?sho...ic=14293&hl=

Most of the complications stemming from tourniquet use are either the result of direct pressure on underlying tissues or the byproducts of ischemia distal to the site of application. While most of the complications that have been reported in association with their use (both for control of hemorrhage and as an adjunct to surgery) have been localized, there are systemic complications that can result including thromboembolic events [78], most notably pulmonary embolism; renal failure due to rhabdomyolysis [79-84]; lactic and respiratory acidosis, hyperkalemia, arrhythmias, and shock[85].

Full Article:http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2151059

In other words this clinic was trying to cover something up that should not have been done in the first place? Otherwise why did they not act? From what I have heard most places will not abort after 12-16weeks gestation. Correct me if I am wrong, but I did not know that they even abort at that stage. It is murder, that nurse suffocated that baby.

When I am in the shower and its ten below.