fireflymedic

Good input guys - like the fact you all had the answers you did. In my position, I'd tell or want to be told first. Thank God I haven't had to face this bullet. I've kept me and my patients safe so far and hope I continue to. Be vigilant, be safe !

This isn't so much a patient treatment scenario as an ethics scenario aimed more towards medics, but basics can put in their thoughts too. Thank God I haven't had this happen to me, but I know of others that it has and just wondered the general attitude of how you have or would handle it. You are dispatched to pick up a 33 year old female with chief complaint of isolated fracture to the humerus. Enroute, she begins to complain of pain again (you are on a transfer). You consult with med control and they order 2 mg morphine. You draw it up to administer and push it. About 5 minutes later pt's pain has gone from a 8 to a 3 out of 10. Upon cleaning up the truck after the run, your basic partner finds the vial you used and it's marked diazepam (valium). Instead of giving 2 mg morphine you have given 2 mg valium. Your patient has suffered no ill effects to your knowledge, however it is still early. They did however report decreased pain which is what you were trying to achieve. How do you document this? Who do you tell? Will you tell ER doc of your mistake? Your chief? What will you do different the next time to prevent this error? Will you even tell at all? I'm looking for honest answers here. I'm just curious to see how things would be handled. I'll give my thoughts at the end of the scenario.

Two boots that I like - Rocky's (I wear paratroopers, not ST though) though they can get a little heavy after being on your feet all day long, but very comfortable. Found alot of other medics that are fond of them too. Also really liked magnums. Have a pair that after 6 years of 5 day a week use, they've held up great (but very scuffed). Worst ones I ever had were Galls brand - the entire sole fell off one day after only owning them about six months with light use (the soles are just glued on). I was very irritated, fortunately employer bought them for me so I didn't have any money invested, but they were a waste of money across the board. Defnitely wouldn't recommend them. For the money, I'd say either Rocky or Magnums.

Yes everybody, I think this is a good thing, however, I'm starting to wonder if we aren't digressing with the basics just a bit with it. Taking away their combi tubes, nitro (though I didn't like the idea of giving it without a line anyway even if BP was okay it could still really drop it), then adding IV's giving narcan, D-50, and sub Q and IM epi. I don't know about other states, but here our basics already hold most of those skills short of the IV's. Do they plan to do pharmacology along with these meds and increase the training along with it? I'm glad we are moving towards having standard skills across the country and not having 50 levels of providers. On the flip side though, how many feel we are taking a step back in progression regarding basics or do you feel we are improving things with the institution of advanced emt as opposed to intermediates despite the reduced privledges (depending on I 85 or I 99). IV's, IO's, narcan, d 50, nitro, and of all things nitrous? All for people with just a few hours over basic training? How many hours will they add on to get people to this level and will bridges be offered? Also, my understanding was that critical care paramedic was going to be considered in the scope, but in the final outcome I'm not seeing it so are they refusing to recognize that certification or will it be simply an additional endorsement? Any insight on this is appreciated. I know TN went to this (short of narcan which they are now considering) a few years ago and seem to have had good success, but it also eliminated first responders and almost did basics (no new certifications). Cross the border a bit and head to OH and you have basics intubating. GA, you can't even get on an ambulance without being at the I 85 level. These are just the states I have experiece with. How do you see this going over across the country and do you see some states bucking up and refusing to adopt the new standards? Give me some input.

My thoughts on bystanders is they can be useful in certain situations, however most of the time they are simply a hinderance to our normal functioning process. Now, that being said, if I'm at walmart and see something happen I'll offer to help, but by no means am offended if they tell me go away. It just depends on the situation, and if there is anything I really can do to benefit someone or just stand there in the way. However, once EMS shows up, I tell 'em what I know and get outta the way. It's their show then. If help is needed and I can do something, by all means I'll offer, if I'll just be in the way, or they have it under control, I'm not going to impose. My thought is it's kinda like this for all the fire people in here - if you were driving by and saw a house on fire, and saw nobody around, you'd have enough sense to call and say hey there's a house on fire. You wouldn't however, try to grab the local FD's pack and your turnout gear and try to go running in with them. They've got their own system and what works for them and they don't need your intervention - you're a liability and just in the way. I have enough to do when I'm on duty that I don't need to go looking for it off duty, but I would never walk away from someone who truly needed help and there was no one around to help. Just my humble two cents.

+2 kaisu !

Mateo - good thinking, however remember that with increased perfusion pressure, you are also increasing the possibility of increased swelling. You have herniation going on already, the brain has no where to go but down. You increase that pressure, you are just killing the person faster. MAP of 60 will do you just fine. Any higher and you'll see the patient going downhill much faster. Remeber with an IC bleed you are just increasing the pressure already within the brain and if you push that CPP higher it's not a pleasant result. Keep enough flow to keep tissue alive until they reach definitive treatment (around 60 or so especially with the transport time we had) but not so high you push them over the edge (had we maintained as high as you stated our patient would have been long dead before reaching ER). Keep learning though - you got good thoughts, I'll ride with ya anytime !

as long as you can keep a MAP of 60, I can live with a lower BP therefore, you're not needing such a high BP. You can have a lower BP and still be perfusing adequately. DAI is drug assisted intubation - give enough sedatives ie valium, versed, ativan whatever flavor of the month to knock 'em down and hopefully relax enough to get the tube - no paralytics given at any time. RSI involves use of paralytics. Basically with DAI you are not fully taking away their ability to breathe, just let meds wear off a bit and they'll pick back up, RSI you are taking that ability away. Nice job.

Nice work Mateo - you hit it on the head - had massive IC bleed. Only disagreement I have with your treatment plan is keeping systolic above 110 - I'll take 90-100 so as not to increase ICP any further. I did end up getting the tube - courtesy of drugs to loosen her up (got DAI not RSI due to no second medic being around), but I could imagine the nightmare if I hadn't had that luxury. Bleed wasn't due to trauma that we are aware of - doc's best guess was aneurysm. The general sickness was probably a headache leading to this that they dismissed. Pt coded in ER and they didn't get her back. The end. Good thoughts and playin gang. I'll ride with some of you all anyday

Okay, I like your thinking sleepy - suction started with hand vac which we carry in our jump bag - yeah they suck, but they work okay in a pinch. You go to intubate, the patient and they are clenched. FYI (RSI is an option if you want it) Sorry about the chart, you never did get it - just outta luck there. Patient is now boarded and out in the truck. I know you all want a helicopter so bad you can't stand it, but do you REALLY think you're gonna fit a 400 + lb patient in a little bell 407 which is what alot of the locals around here fly? Uh no. So sorry on that, you get this one one your own. Now let's get down to the nitty gritty - what's going on with this patient? What other interventions you gonna do to benefit ?

This was a real scenario - complete from my last shift so anybody wanna come work with me? Okay, here's some vitals to let you start playing BP : 180/110 RR : 8 - snoring, inadequate HR : 64 SPO2: 80% on room air Pupils : dilated, very sluggish to react BGL - 72 Vomit : greenish yellow slime with chunks of what once resembled carrots in it AVPU : unresponsive GCS : 5 - (1 eyes, 1 verbal, 3 motor - appropriate flexion to painful stimuli) Monitor : NSR - no ectopy present Your partner finally chases down the cafeteria worker who tells you one nurse just walked out on the job and she doesn't know where the other one is. She tells you best bet is to find an aide. On the way, a janitor informs you that the elevator is broken so you'll have to carry the patient down two flights of stairs. You call for fire who informs you they are busy and you will have to call the jolly volly rescue squad (they inform you they will respond as best they can - show up with 3 people). Your partner finally returns with an aide who says "oh crap, that's her" and runs off. An additional BLS truck is 30 min out with no other ALS available.

You are a rural EMS service called to "steven king's rest home" which houses both the elderly and mentally challenged together for a sick person. Upon arrival, you enter the abadoned looking facility searching for a nurse to get a room number of where you need to go in the four story facility. You cannot find a nurse to get any information, so you start going from room to room when you hear a large thud from the floor above. You go upstairs to investigate (still trying to find a nurse) when you see a door dislodged from it's hinges. Upon opening the door, you find a rather large female (approx 400lbs) on the ground, naked, covered in vomit and urine and cyanotic. She is completely unresponsive and you begin care for this patient - what would you like to know or do? You are the only truck available with over an hour to the closest hospital. Your truck is a basic/medic configuration.

This has been a topic which I feel has been thoroughly discussed and hashed out as to possible outcomes. As new EMT's or those of us that don't work as often, get caught frequently by the fakers. Hey, it happens, if you treat 'em as real, you'll still be okay. Yeah, the ER doc might go "why did you? They are a frequent flying faker" but my response is them, "I worked too hard to get this cert to lose it to stupidity". Even though I'm on the truck between 3 and 4 days a week, I occasionally get caught. Now granted I'm not going to waste my time and resources as well as my department's money (as these patients usually don't have insurance to reimburse) doing the $10,000 workup on them every time. I will however get an IV on them, put them on a little oxygen and monitor vitals. Easy to do, really doesn't take much time, and will benefit. If they seem to deteriorate, or something presents itself, then I'll get more aggressive as needed. I will admit though, during my tenure of working in an ER in a place known for drug seekers, there was more than once I did inform a patient that was faking unconsciousness that if they didn't become conscious that some very unpleasant things would begin occurring. All it took was a resident or two to start mentioning the phrase intubation and catheter and usually they perked right up ! I've not felt the need to do that since back on the truck, but two very different atmospheres requiring different approaches.

One word of caution though to the ones saying that all people with seizures lose consciousness - not all do. Certain types such as myoclonic jerks, jacksonian seizures (which may not spread all the way), and partial seizures can cause twitching/shaking to one side or part of the body without a loss of consciousness. The person may be totally aware and telling you "I'm having a seizure". However, most of the people I have found deal with a specific hospital as they are aware of this and are aware that the person isn't faking. It was a good education for me the first time I dealt with a patient like this. I was kinda like, huh, cool ! I'll be first to admit though, many times you can tell the fakers a mile away, but not always. There's alot of people out there fishing for meds, especially in really rural areas like mine (yep, it's the high they don't have to pay for !) or the inner city where people just plain out want drugs, though you could find it anywhere I guess. Most of the people I've found in suburbs asking for pain meds just have quite a low pain tolerance. Amazingly it seems the ones I'd be liberal with pain meds on are the ones that don't request as much - strange eh? Be safe.

+2 Doc - couldn't agree with ya more. When I worked in ER I got to see my fair share of 'em come through that were "socially intubated" due to their mental status. Many had serious medical issues which may not have been detected otherwise (their violence would have prohibited any reasonable exam), others were just *ssholes. On my truck, I don't tolerate violence be it for a medical reason or not. I'm 5'2 and don't weigh enough to fight with someone 6'6 and 350 lbs tanked on meth - that's what the troopers are paid for and I have no problem using them for that. They are there to make sure my butt comes home every night ! I've been in that situation before, and it's no fun. Had the entire cabinet side of my ambulance destroyed. Guy was hurt, I was hurt, and just not a good situation all around. If you can't respect me, or if you have medical/psychological issues to where I can't adequately assess and treat your condition you're winning a round of meds. If I max out what I have available to me to use, and I've got a long transport (ie transfers sometimes 2 hours plus to trauma/specialty centers) then good night, sleep tight. The truck is too small for me to be thrown around and you are compromising my safety as well as your own. Enough said, be safe.

AK - I had a similar experience early on in my career where my partner handed me a note saying "she just wants attention" to a little old lady who just said she felt bad. We ran on her all the time. Well, I was the sparky eyed new basic so I still did the O2, gave a decent assessment. Got her to ER and doc later revealed she had massive MI. Lady died two days later. Was a hard lesson learned that the faker one day may be for real. The faker may be a pain in the neck and time consuming, but sometimes there is a reason behind it. Had a lady that used to fake seizures so her husband would stop beating her and called 911. Was her way to escape the situation. Best coping method? No, but I could understand where she was coming from. Also, don't forget those fun things called atypical presentations. Not every patient reads the textbook, so sometimes you see weird stuff, but it's okay, we live, we learn, and we go out on another call the wiser for it hopefully. It's only when we think we know it all and stop learning that we get ourselves in trouble. Be safe Fire_911medic

Doczilla, one other one which I forgot that is quite useful for nasal intubations - neosynephrine which comes in a spray, but is given IN anyway. Though nasal intubations are falling out of favor very quickly with the more widespread use of RSI/DAI in ground services. I believe I've only had one nasal in an 8 year career.

hate to hear it - we lost one not too long ago. Unfortunately there are too many of us getting hurt of killed these days. Prayers for his family and coworkers. Be safe.

another useless death - sad. Prayers for his family.

I know ativan can be given rectally, so my assumption would be that IN would be fine as well, however, I've only had experience with versed which I am definitely preferable to as I am most comfortable with it. I have used ativan in other situations, but only IV, so that's where my expertise ends sorry. As far as using it to sedate psychs, if you can control the head well enough to get a good administration, and are able to turn them or handle the vomiting issue, go for it. IN is a faster method of absorbtion than IM, so that's a definite benefit there ! I like to restrain psychs via spider straps on a backboard 'cause I think it gives me the best and safest form of restraint which I can justify. Good luck !

hey, just set one of the "thumpers" really fast and you'd have it !

Firedoc, As far as drugs being able to be given down the tube - valium is no longer being given down the tube as it is oil based so the new acronymn being taught is LEAN (lidocaine, epi, atropine, narcan). I'm not sure if versed could be given via ET tube as I've never given it that way. As far as giving drugs intranasal, the best method of administration by far is the MAD devices. They are fantastic ! I've done versed, narcan, and stadol that way. Works great and definitely beats rectal administration anyday ! Only issue I've found with IN administration is that some of the drug occasionally drains down the back of the throat, obviously has a bitter taste and may cause vomiting, so just be prepared for that. I'm fortunate our service carries the MAD devices, so I've never had to give IN via syringe and cath (please do so without the needle !) but I could see it given that way.

Has anyone here experienced difficulty with employment due a disclosure on a pre-employment physical of a medical condition/prior surgery/etc which they were cleared by their personal physician, but later denied the job due to this? At what point can an employer say "you're an employment risk" for something which may never cause a further problem? I ask this in relation to things such as back screenings. A lot of people have minor abnomalities in their backs which may never cause a problem, however, I know of several who were denied jobs with better services because of this, went on to work other places (though for not as good pay and benefits) retire out with no problems after 20 years of service. I ask this because of a situation I am currently encountering and without stating too much as to reveal this person's issue, I have some concern (for one of the first time's in my career) that they may not be adequately able to hold up to the demands of EMS work due to joint replacements. The person already is limited in some activities and with the nature of joint replacement limiting range of motion and possibly instability on very rough terrain such as with mountain rescues etc which are frequent in our area - how would you all handle the situation and moreover, what responsibility do I have to address this situation with the person and/or their physician? Thanks.

As far as psychs and deaths due to positional asphyxia it's not just due to being placed prone. It's the position their head is in. Also, some succumb to cardiac arrest due to the combination of drugs in their system in addition to the struggle they present to EMS/PD. Best approach with this situation is to administer some form of chemical restraint with the least amount neccessary to do the job effectively. Then apply appropriate restraint (I'm a fan of spider straps and tying the hands as if I were gonna fly 'em) maintains good IV access, appropriate restraint, and much more difficult to get out of as well as providing restraint to key areas preventing bending of knees and arms and raising of head, neck, and chest. An alternative if you don't have spider straps is to apply cravats across the chest, knees, ankles, stomach and tape head down. Take one arm and secure to head of stretcher behind patient's head and the other to the side rail. Prevents them from using both major muscle groups. Both work quite nicely and are considered appropriate restraint.

I'll be the first to admit, OB related calls are my weakness. We don't see many of them, so when I get called to something OB related I feel that I am inadequate. I wish we did more training rather than avoiding training in that area so I felt better equipped to handle those situations. My strong point though is cardiac. Give me a heart, and I'm happy.