fireflymedic

I think that particular company you are discussing fiznat, it is dependent upon where you work, similar to rural metro or other large companies. I've heard people that work rural that love it that were based in other areas. Here they are a joke. The same holds true for the company you discussed as they do not have the 911 contract in the area. However, I understand in other areas people are quite content. I've not worked with them, so I can't speak for it, but overall in this area, I've not been impressed because they pull new medics/basics, throw them together and say good luck with poor medical oversight. As I stated though - this may be solely this area - I can't speak for other bases. It sounds as if you've got a good gig, so enjoy. Glad you are content where you're at ! That's what it's all about !

Vent - point well taken.

Here can titrate to effect if CCT - not a regular medic transfer. Run of mill medic can't even take propofol. Was just curious about green pee Vent Medic 'cause I know it's been seen in pt's over 48 hours - had one not too long ago that I posted about that was a transfer pt of mine. I'm definitely suprised to see how commonly it's used, but the quick on quick off action is probably what is making it so popular within ICU's - requires much less wear off time. Also, transport a pt on diprivan and you can wake them up to do neuro checks as needed so I can see the benefit to that whereas with other sedation especially depending on size of patient and length on it may take considerably longer. I am curious - was changing the sedation an option here CB or were you forced to stay with what you had? If you gave us fentanyl earlier, you could even give a bit more fentanyl for sedation/analgesia and back off the diprivan some. Just thoughts.

www.mediced.com is a pretty decent site. Know it is approved by registry the CECBEMS I think it is - I've done several of my recert things through them and had no trouble. Complete, and print with the number on it. It's all good. Cheap and easy plus lots of topics to chose from. Good luck.

I'm still hearing good things from the other side of the fence about starflight but all well each has his opinion. As far as being on the ground - well I'm quite content where I'm at I really don't have a burning desire to leave. Involved med director, good education, training, coworkers with balanced heads, new equipment, great protocols, and high true 911 volume, not B.S. crap and a long transport to use our skills, yeah, this is heaven for me. Now if I were to move to the air I would have once said stat care of louisville, KY 'cause they were just all that and a bag of chips, however I sadly see that changing very quickly since the buyout. I already see a major change in care and good medics/nurses leaving in droves. That being said my next choice would be Vanderbilt Lifeflight - either ground or air they are just cool and have a right to think their all that. Good skills, they earn it ! Truthfully though, I don't see myself leaving where I'm at any time in the near future unless some things go very south.

CB - propofol infusion syndrome - by chance do we have green pee? He definitely fits the bill here - critically ill patient, long term propofol, tachycardia (though bradycardia is an effect sometimes as well), myoglobinuria, rhabdo, and metabolic acidosis. Sounds like he fits the bill pretty well. Took me a bit to get there, but I think we did. One fun side note though, when was last time tubing was changed? Diprivan is known to be bacteria friendly especially if tubing not changed every 12 hours - could he also have some little critters growing in there? Just curious. You made my brain hurt CB ! Good scenario though. Oh, as far as what to do about it? Is changing sedation to versed/fentanyl an option? That would be my preferred way to go anyway since this guy's been down and prolly gonna stay down for a bit - will they be doing daily awakenings or no? If not, let's change the ticket here and problem resolved !

here's my thoughts - the rhabdo is causing the metabolic acidosis. The thoughts crossed my mind earlier, but at any rate - I'm still suspect that there's not some sepsis going on.... labs still make me think that direction. If diprivan is processed through liver - and liver affected, it is contributing to the problem. You state propofol was given for 48 hours - not that long, but long enough with liver compromise. The stress of trying to process the diprivan is contributing to the metabolic acidosis as well. IMHO - this is one very sick guy. Glad you're flyin with him and not me !

Definitely acidotic state here no arguement about that. With serum lactate of 6, he's already to the point of severe sepsis so my strongest suspicion is that he does have a septic state going on. With that info, I'm going to say that the sepsis is affecting his kidneys in some fashion and is contributing to the metabolic acidosis as renal insufficiency is a contributing factor to metabolic acidosis. Did intestine area get nicked with shrapnel and missed so this poor guy has some bowel involvement? Also, the hypotension if prolonged can compromise kidney function as well. Is this guy still on dopamine? He's also tachy (with as you said the unsustained runs of v-tach) so that makes me lean even harder towards a sepsis diagnosis. As far as antibiotic choices - you wanna go broad spectrum - vanc being first line since we don't know what bug we're dealing with yet (though I'm suspecting gram neg). Zosyn is another option to throw which is a good one for sepsis. That's as far as my brain's thinking thus far this morning.

What is sepsis due to? Kidney function? Urine output? Vent dependent? Settings? ARDS an issue? Do we require vasopressors? If so how much and what? Gram negative or positive cultures? What antibiotics are we on? Current vitals? Stability of patient? Is this gonna be a happy flight or am I gonna be working my tail off here? I think I'll let you have that for the time being? Oh let's throw age, coexisting med conditions, duration of sepsis, and routine meds in addition to the boatload he's prolly on right now.

Dang dust - I knew some of my partners resembled chimpanzees, but now I know why ! Have you worked around here at some point?

Well - I've held my tongue this long - I guess it's time for me to jump in here. First - you all will notice I have not, nor will I ever "bash" a basic. I cannot and will not tolerate the paragod mentality. God forbid anyone view me in that attitude. Second - that being said, a basic is truly nothing more than a glorified first responder. It is an appropriate level for a police officer, firefighter, rescue squad member, etc that are nothing more than first response. It is there to assist me when needed on scene and to have the minimal basic knowledge to prevent them from killing my patient. They can be helpful, but they do not, nor should I expect them to have the understanding and comprehension of why and everything that I do. That comes with experience and also education. Something that no matter how motivated the EMT - 120 hour course simply cannot teach. Third - any service that places a fresh medic on the street with a basic isn't worth a hill of beans. I've learned that in my time as a preceptor and instructor with 8 years experience behind me - 10 in total for EMS. A new medic should shadow a seasoned medic for at least a year to gain experience and build confidence. Especially in areas similar to where I am. A new medic that loses their composure is worthless. It's not fair to the medic, the partner, or the patient. Fourth - yes I am an advocate for progressing education because I want to see ems workers viewed more as a nurse is as a professional and recognizing those of us who worked hard to obtain degrees to finally be compensated for the amount of money that is spent pursuing them. My degree involved inorganic, organic chemistry, a semester each of anatomy and physiology, composition, calculus, microbiology, in addition to physics, a semester of cardiology, pharmacology, &other supporting courses. I could have applied easily to medical school with my degree and satisfied all the requirements for admission. I considered it, but decided against it for now. I may revisit that option in a few years. My degree is in emergency care and fire science. I am proud to say I have it, and I have definitely found it beneficial to me and helped in the understanding of why I am performing certain interventions or why the body is behaving a certain way in a disease process. I don't have the understanding of a physician, but I feel well prepared to care for my patients. Finally - I view the "levels" of ems similar to nursing. A basic is the equivalent to a CNA - you are there to assist the medic but not enough to truly care individually for the patient. It's your starting point, and yes you should have some experience there - though time at that level is debatable - however who wants to be a butt wiper for the rest of their career? Most strive for better. An intermediate is similar to a nursing student in clinicals or an LPN,a taste of true nursing, but not fully competent to be on their own yet, but much more independent and knowledgeable than a CNA. Finally a medic should be the equivalent to an RN. Granted nurses are taught little about a lot and medics alot about a little, and the demands are different, but the degrees should be viewed as equal promoting a more professional view of paramedics. Keep in mind I've had some fantastic basic partners that will be excellent paramedics because of their attitude and their willingness to learn. I'll also say that using a basic or intermediate for nothing more than a gopher is not benefitting either the medic or the lower level who may be trying to learn and is working at that level while pursuing higher education. As others have stated I've also known some with a know it all attitude that be a basic or medic I would never want to work with them. They are a disservice to their patients. The paragod mentality no matter the level will get you nowhere. Stay safe and smart everyone.

Sowtech - I feel the pain on WV forms - needless to say I've used more than one ! I was told I was wasting paper when two sheets were needed to adequately document a run. I never have the problem with the service I'm with now. I've never had my documentation questioned by anyone and I try to get as thorough as I can with dialysis, trauma, medical, whatever patient I have. It doesn't make a difference what my type of patient is, I'm going to document each one and each refusal as if everyone is going to court. That ensures that I am well covered at worst case scenario I am questioned and also that if my patient or anything is required for future care they that the info that they need. Just my thoughts.

I know here in KY as well as TN and OH which I routinely operate in you are highly unlikely to be certified. In fact, it is a challenge within KY to be certified if you have a misdemeanor regardless of what it is. Mind you that is CONVICTIONS ONLY. I know of several people who had charges brought against them, but due to the fact that it was charges only (anyone can be charged and sometimes mistakes are made) and later the charges were dropped, or a unique situation they still retained or were allowed probationary certifications. General rule of thumb for the above is 5 years for a misdemeanor, not at all for a felony. Though nothing regarding a situation where you delivered or were attempting to deliver care or involving children (though I do know of two situations regarding children that weren't what presented as and the person was allowed 10 year probational certification and not allowed to pursue medic during those 10 years). I do know KY, OH, TN, and WV run criminal background check. Heck KY runs them as frequently as every 90 days for medics or students. I used to see stuff from the court system or state board all the time. Also, WV requires a copy of your fingerprints on file with state police and background check run. I can't speak for FL, but I would say in general you have quite a bit of explaining to do and I would really push to get an answer from the state board and submit all the information into their investigators. Ask for an in person hearing if they do a review so they can speak with you and see where you are coming from. I understand anyone can make a mistake in their younger years, and I don't believe that should ruin them for life depending upon the offense of course. I dare say it would be easier to obtain certification as a basic as opposed to a medic with a prior felony conviction, but again it depends on the situation and the state. Best of luck to you.

First, deepest sympathies to families and coworkers. How terrible to hear this yet again. I dread reading the news anymore for fear that I will hear of yet another one. I'll not make judgements on the crew or their decision to fly, but I will say this is happening all too often. As ground people, I think we really need to re evaluate how often we are calling and make sure they need it before we risk another crew. God speed to them.

Here's a situation that kind of relates to a BLS/ALS deal that I actually dealt with several years ago. We performed mutual aid for a BLS service near the TN state line - there I held emt-iv certification, when crossing the line into the other state where our primary service was I was nothing more than a basic which actually quite restricted scope of practice due to state. IV's aren't even considered. Here you are either a basic or a medic. Nothing in between. Well, we had protocols in place that if in TN, I could start IV's as could anyone who held the certification. D-50, albuterol, sub Q epi, narcan, etc were some of the other things permissible. One day we were transporting a pt and the closest hospital was in TN. In my state I could do very little for this diabetic pt. ALS was not an option as there was one medic to staff the entire county per shift (and he was only on call). When in my state I couldn't start an IV something I was proficient at doing and administer D-50 which would have seriously benefited my patient. As soon as I crossed the state line, our individual protocols and TN scope of practice allowed me to do both significantly helping my patient. However, had I had to transport to a hospital within my state, the patient would have had to wait for the hospital to administer. With the long transport times we faced, that could have been potentially detrimental to them. Would I have started an IV and given the D 50 and risked my license? Absolutely not even though it was within my scope of practice across the state line and within our protocols for the same. I know of a few others that didn't agree with this mentality and only three are still practicing EMS. They were brought up by the state for practicing medicine without a license. They no longer have certifications even though they were trained and understood what they were doing, it was outside protocol and scope of practice for my state. It's never an easy decision, but do you want to help several people or just a few? Losing your license benefits no one.

Doc - nice thought, but no, she's not a TCA overdose ! She is a result of X. Being out dancing all night, dehydrated, constant activity with limited water intake has caused the palpitations and other issues. She has an elevated body temp from this - the girl's cooking from the inside out. X isn't the harmless drug we once thought it to be. If the people do not maintain adequate hydration, it can lead to imbalances causing the above symptoms in addition to some not listed in this scenario. Keep your eyes open and your brains thinking ! Stay safe out there !

My sentiments exactly doc - thanks for jumping in.

She thought it was asprin, but who knows what it could have been - you're on the right track buddy - trust me you aren't far away !

EKG is sinus tach, no ectopy Richard - you are definitely getting warmer, approaching the right temperature actually just need to go up a few degrees She states she never had her drink out of her sight and claims she took some asprin earlier for a headache that someone gave her. She remembers everything and is fully clothed, but just seems a little shall we say out there?

Dwayne, as I stated it is each individual person's decision and each person has to live with that decision. I can't say what is right for you, nor can you say what is right for me. I think we both have enough class to respectfully disagree here? Opinion respected. I don't think there is a final answer as to what is right or wrong here and to continue to debate it is simply beating a dead horse, so personally I'm done with it. I will say if I know a procedure is detrimental to my patient, and ordered by med control, and within my scope of practice yes I would question - possibly even refuse that treatment. I consider that my responsibility and advocating good medicine. Docs aren't perfect, they make mistakes too. However, if something is recommended and I refuse to do it, I had better be prepared for the consequences because as an MD or DO he has far more training than I and may be aware of a contributing factor that I am not. I better have a full understanding of why I refused the procedure. Dwayne and others, I respect your decision whichever way you choose and I'm sure neither decision would be made lightly. I can tell that from the discussion in here. I believe the best response to this question is your personal decision which is what was asked, rather than what is "right" or "wrong". Be safe everyone.

You are toned out to an abandoned warehouse where a multitude of teenagers and college students are collected. The noise inside is almost deafening as you barely get the information telling you inside is a 20ish female who has collapsed on the floor. Bystanders tell you she has been dancing almost all evening (about 6 hours) and a little bit ago was complaining of palpitations and dizziness. The girl is able to speak to you, but acts disoriented, but is still able to relay basic information. Here you go 21 year old female, no pertinent medical history, showed up at party about 6 hours, says only meds she's on is antidepressants but can't remember what named. Her skin is flushed and dry, pulse is rapid and weak at 124, BP 100/60. She says she feels like her heart is racing, then skipping beats complaining of minor chest pain 2 out of 10. What would you like to know?

Here is my thoughts on the topic for what they are worth. Most of the research is done in urban areas where hospitals are no more than 15-20 min away at most in traffic. Most places have multiple hospitals within easy reach of them. If they were to conduct their research in rural areas, the opinions might be quite different where the transport times are much longer (mind you along with response times) so patients are in much different positions than say in the city. Having worked both urban and rural EMS I can say there is a definite difference. I can see how in a urban setting within minutes of a hospital ALS capabilities and benefits are limited. However, I disagree strongly with this theory within the areas I serve. It's definitely a different ballgame. You don't believe me, come ride with me for a day. I disagree with the comment that the treatment I have provided has not made a difference. Many times, my ability to respond and treat on scene and release has allowed people who could not afford an ER visit or transport to receive what they needed. Perhaps in other areas it's different, but I do see the difference my services make every day. That being said, good BLS skills are essential to any caregiver and I will NOT waiver on that decision. Anything from a first responder to a CCT medic need to have excellent bls skills, the most important of those being truly good assessment skills (the biggest thing I see lacking in new hires at surrounding departments). As I've said many times, your box of toys fails, you have to still manage the patient BLS and those skills better be excellent to give that patient a fighting chance. Basic or medic it doesn't matter, you have to assess, treat, and manage your patient to the best of your ability. No need to fuss about who's better and who's not. And just a side note, while I respect Dr. Bledsoe and believe he does have EMS best interest at heart (or at least seems to) he needs to investigate some into EMS beyond urban settings before making comments. I must respectfully disagree with him on this issue.

nice to see I haven't made the misbehaving list yet !

Dwayne - in no way, shape or form did I say don't advocate for your patient. I am all for medics and basics and anything in between advocating to give their patients the best care humanly possible. That was actually the key point of my post which sadly you missed. It is our responsibility to ensure they get the care they need and the best possible care that it can be. Now, as far as your insult as to the medics I spend my time around I beg to differ. I was speaking among services I have observed. The service I operate within has well trained, experienced medics that I wouldn't think twice about trusting mine or my family's life too. They are actively involved in research for improving patient care and always looking for ways to better their skills. I truly believe they are among some of the best in the business and most compassionate about their care. Please do not show your ignorance by speaking of what you do not know. Exceeding your scope of practice is practicing medicine without a license. If I can get someone more qualified to be responsible, by all means I will. That is not to say that I won't go toe to toe with a doc (and have before) questioning how a patient was treated because I wanted to know his reasoning behind it when I thought there might have been a better idea. I don't know it all and I'm all for the opportunity to learn. That is what being a medic is about is educating yourself and your patients and promoting the best care possible for them. It's not about being the person that exceeded his scope of practice 'cause he "thought" it was right and end up possibly causing more harm than good. If you had the situation that you performed an action and didn't know all the contraindications and indications for it and ended up causing harm potentially killing your patient then was exceeding your scope of practice worth it? In this thread we've only discussed positive results from people exceeding their scope of practice, but there's enough things that go wrong when you are properly trained that can cause negative results, if you weren't within your scope of practice, that's career suicide. We all sit back and say we couldn't live with ourselves if we watched a patient die because we thought we could do something, but what if the patient was bad and your actions made them worse or killed them - could you live with yourself then? This comes down to each person's individual thoughts and convictions, but personally we should all remember the biggest rule - first do no harm, and if your actions should on the off chance not help but hurt the patient you have done just that. Caused harm. How would you answer those questions when faced with them? Would you still feel justified and how would you justify it to that patient or their family. Think long and hard about what you do. The results will last a lifetime. Always be safe and smart out there.